Conditions: Type 2 Diabetes Mellitus Obese Overweight
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 24
Healthy volunteers: no

Brief summary:
To study the effect of an ileocolonic formulation of ox bile extract on insulin sensitivity, postprandial glycemia and incretin levels, gastric emptying, body weight and fasting serum FGF-19 (fibroblast growth factor) levels in overweight or obese type 2 diabetic subjects on therapy with DPP4 (dipeptidyl peptidase-4) inhibitors (e.g. sitagliptin) alone or in combination with metformin.

Detailed description:
This is a single-center, placebo-controlled, parallel-group, single dose, randomized, controlled trial. Participants will receive 28 days (+/- 4 days) of treatment to study the effect of delayed (ileocolonic)-release ox bile extract 500 mg BID (twice daily) on insulin sensitivity, gastric emptying of liquids and solids (measured by scintigraphy) and weight loss I overweight and obese type 2 diabetic subjects. Participants will be receiving therapy with DPP4 inhibitors alone or in combination with metformin. Blood samples will be collected at defined times to measure glycemia, FGF-19 and incretins (GLP-1 \[glucagon-like peptide-1\], OXM \[oxyntomodulin\], PYY 3-36 \[peptide YY\]) fasting levels and responses to the meal.

Arms:
arm 1: Ox bile extract 500 mg tablets taken orally twice daily for 28 (+/- 4) days Gastric Emptying test, Waist and hip measurements, Mixed oral glucose tolerance test, Blood tests arm 2: Matching placebo tablets taken orally twice daily for 28 (+/- 4) days Gastric Emptying test, Waist and hip measurements, Mixed oral glucose tolerance test, Blood tests

Interventions: intervention 1: Gastric Emptying test intervention 2: Mixed Oral Glucose Tolerance test intervention 3: Conjugated bile acids sodium intervention 4: Placebo
Intervention descriptions: intervention 1: participants eat a standardized meal labeled with radioactive markers (99mTc DTPA \[diethylenetriaminepentaacetic acid\] and In111 Chloride). They have scans taken at specific times after the meal to document the rate of gastric emptying. intervention 2: Participants eat a meal containing 63g glucose in 240mL (milliliters) of skim milk, 2 scrambled eggs, 50g Canadian bacon and one slice of bread. Blood samples are taken prior to and for 6 hours after the meal at specific time points. intervention 3: 500 mg tablets taken orally twice daily for 28 (+/- 4) days intervention 4: Placebo tablets taken orally twice daily for 28 (+/- 4) days

Protocol document:
Prot_SAP_000.pdf: 
- 0 - 
 
 
Effect of Delayed-Release Bile Acid on Insulin Sensitivity, Gastric Emptying and Body Weight in 
Overweight or Obese Patients with type 2 Diabetes Mellitus 
 
Version 1 
Dated 11/23/2015 
 
Principal Investigator:    
• 
Michael Camilleri, M.D., Division of Gastroenterology and Hepatology, Department of Medicine, Mayo 
Clinic, Rochester, MN    
 
Co-Principal Investigator:    
• 
Andres Acosta M.D., Ph.D., Division of Gastroenterology and Hepatology, Department of Medicine, 
Mayo Clinic, Rochester, MN  
 
Co-Investigator:    
• 
Adrian Vella M.D. Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN;    
• 
Alan R. Zinsmeister, Ph.D., Division of Biomedical Statistics & Informatics, Department of Health 
Sciences Research, Mayo Clinic, Rochester, MN.  
• 
Duane Burton B.S., Division of Gastroenterology and Hepatology, Department of Medicine, Mayo 
Clinic, Rochester, MN;  
 
Nurse Coordinators and Laboratory Technologists:   
• 
Sara Linker Nord, Irene Ann Busciglio, Deb Rhoten, Michael Ryks, Division of Gastroenterology and 
Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN    
 
Project Summary  
 
Background: Intra-jejunal administration of bile acids improves insulin sensitivity.  
 
Hypothesis: The ox bile extract in delayed (ileocolonic)-release formulation, stimulates enteroendocrine L cell 
secretion in the ileum and colon, increasing the secretion of FGF-19, GLP-1, oxyntomodulin (OXM), and PYY3-
36, improving insulin sensitivity and inducing weight loss.  
 
Aim:  To study the effect of an ileocolonic formulation of ox bile extract on insulin sensitivity, postprandial 
plasma glycemia and incretin levels, gastric emptying and body weight in overweight or obese type 2 diabetic 
subjects on therapy with metformin and/or DPP-IV inhibitors.  
 
Study design: This is a single center, placebo-controlled, parallel group, single dose randomized controlled 
trial to 28 days (+/- 4 days) study the effect of delayed (ileocolonic)-release ox bile extract 500 mg BID on 
insulin sensitivity, gastric emptying of liquids and solids (measured by scintigraphy) and weight loss in 
overweight or obese type 2 diabetic subjects.  Participants will be receiving therapy with DPP4 inhibitors (e.g. 
sitagliptin) alone or in combination with metformin. Blood samples will be collected at defined times to measure 
glycemia, FGF-19 and incretins (GLP-1, OXM, PYY3-36) fasting levels and responses to the meal.   
 
Anticipated Results: In comparison with placebo, ox bile extract will increase insulin sensitivity, enhance 
glycemic control, increase postprandial incretins, and delay GE of liquids.  
 
Significance: This study will prove that ileocolonic-release ox bile extract enhances glycemic control in T2DM 
patients.  


- 1 - 
 
Background and Significance  
Obesity and Type 2 Diabetes Mellitus (T2DM) are chronic illnesses whose prevalence have reached 
epidemic proportions in developed countries and are increasing in developing countries.1 In the USA, the 
prevalence of overweight adults is 64%, and obese adults is 30.5%.2 This alarming obesity epidemic poses a 
heavy burden to the U.S. economy, costing more than $150 billion every year—10 percent of the total health 
budget—according to the Centers for Disease Control and Prevention (CDC 2012). Patients with obesity are at 
a higher risk of a new-onset cardiovascular event and type 2 diabetes.3 Nearly 24 million Americans suffer 
from diabetes and its associated co-morbidities. Diabetes is now the fifth leading cause of death in the US.4 
These alarming statistics reinforce the urgent need for research into the prevention of diabetes, and the 
prevention of the progression or complications of diabetes.   Currently, the most effective treatment for obesity, 
metabolic syndrome and T2DM is bariatric or metabolic surgery.5                                                                                      
The efficacy in obesity and T2DM of metabolic surgery when compared to caloric restriction suggests that 
the mechanism on weight loss and reversal of insulin resistance and hyperglycemia exceeds the effect of diet 
restriction and gastrointestinal anatomical re-arrangement as in duodenal switch or Roux-en Y gastric bypass.  
Recent advances on the understanding of metabolic surgery, suggest that bile acids play a role in the 
surgery-related improvement of diabetes. Metabolic surgery results in doubling of the concentration of serum 
bile acids, and increases serum adiponectin and GLP-1. Effects of bile acids in the distal small intestine results 
in weight loss and improved glucose homeostasis by stimulating enteroendocrine L cell secretion, and 
increasing FGF19, thyroid hormone - type 2 Deiodinase (D2) and decreasing endoplasmic reticulum (ER) 
stress.6-9 These result in rapid increase in incretins, increased energy expenditure, decreased appetite, 
decreased hepatic insulin resistance and improved muscle insulin sensitivity.10, 11  
Metabolic surgery; is invasive, has multiple side effects including perioperative complications and long term 
nutritional deficits.12 Thus, metabolic surgery cannot be considered a public health remedy to the current 
obesity and T2DM epidemic, and a low cost, non-invasive approach that is efficacious over a long term is 
needed to fight this epidemic. Our overriding approach is to adopt a weight loss mechanism produced by 
bariatric surgery in a non-surgical remedy for treatment of obesity and T2DM. Specifically, our study will 
address the concept that changes in bile acid concentration in the ileum seen after metabolic surgery could be 
applied by non-invasive pharmacological treatment in obesity and T2DM.  
Prior studies using taurocholic acid (TCA), a hydrophilic bile acid, have shown an improvement in 
endoplasmic reticulum (ER) stress,13 reversal of insulin resistance and restoration of glucose homeostasis in 
mice with T2DM.14  Subsequently, these results were confirmed in obese men and women showing that TCA 
1,750 mg/day improves liver and muscle insulin sensitivity.11 These results were not as dramatic as those seen 
after metabolic surgery. Hence, a subsequent study mimicking the role of intra-luminal bile acids after 
metabolic surgery was conducted by intrajejunal infusion of taurocholic acid (2 g); this resulted in acute 
improvement in glucose homeostasis and increased GLP-1 concentration.10 Recently, we shown that Na-
chenodeoxycholate delayed-released in the ileum and colon produces mild delay in gastric, accelerated 
colonic transit15 and weight loss (preliminary data – unpublished).  
The overall research goal is to study the effect of delayed-release ox bile extract on glycemic control in 
obesity and T2DM. The current proposal is a proof of concept, single center, placebo-controlled, parallel group, 
randomized control trial in patients with obesity and T2DM receiving DPP4 inhibitors (e.g. sitagliptin) alone or 
in combination with metformin, as standard of care.  
 
A. Specific Aims: 
We hypothesize that the ox bile extract in delayed (ileocolonic)-release formulation, stimulates 
enteroendocrine L cell secretion in the ileum and colon, increasing the secretion of FGF-19, GLP-1, 
oxyntomodulin (OXM), and PYY3-36, and improves insulin sensitivity and induces weight loss.  
To study the effect of an ileocolonic formulation of ox bile extract on insulin sensitivity, postprandial 
glycemia and incretin levels, gastric emptying, body weight and fasting serum FGF-19 levels in overweight or 
obese type 2 diabetic subjects on therapy with DPP4 inhibitors (e.g. sitagliptin) alone or in combination with 
metformin.   


- 2 - 
 
Figure 1 
Figure 2 
C. Preliminary data:  
C.1. Obesity and T2DM research: Our research 
group at the Mayo Clinic has more than 30 years of 
experience in proof of concept randomized trials 
and over 300 original articles in gastrointestinal 
physiology and pharmacology; the lab has been 
funded by the NIH for the past 9 years to conduct 
research in obesity (DK67071).     
C.2. Sodium chenodeoxycholate delayed 
release: We have previously demonstrated that 
sodium chenodeoxycholate delayed (ileocolonic)-
release 1000 mg PO daily is a well-tolerated 
medication with minimal side effects15, 16. NaCDC 
(ileocolonic)-release 1000 mg PO daily for four 
days produces weight loss in healthy subjects, 
unpublished data (figure 1) and delays gastric 
emptying (figure 2) in healthy subjects (HS) and 
subjects with constipation predominant Irritable 
Bowel Syndrome (IBS-C) 15, 16. Body weight change 
and gastric emptying were not end points of those 
studies and were incidental findings. The weight 
loss and gastric emptying after ONLY four days of 
treatment suggests that ileocolonic-release Na-
CDC may be a promising method to induce weight 
loss in the appropriate population. Na-CDC is not 
available for long term clinical studies. Thus we 
proposed to use the FDA approved ox bile extract 
as a substitute.  
 
D. Research strategy 
D.1. Rationale: Bile acid secretion increases significantly after Roux-in-Y gastric bypass and bile acids appear 
to have a major role in the mechanism of weight loss after metabolic surgery.  Recent studies showed that 
intrajejunal-delivery of primary bile acids improve insulin sensitivity. We hypothesize that the ox bile extract 
delivered through delayed (ileocolonic)-release therapy stimulates enteroendocrine L cell secretion in the distal 
jejunum, ileum and colon, thereby increasing the secretion of FGF-19, GLP-1, OXM, and PYY3-36. These 
observations suggest that bile acids may decrease blood glucose and improve insulin sensitivity through their 
effects on endogenous incretins, independently of gastric emptying and glucose.  
D.2. Design:  We propose a single center, placebo-controlled, parallel group, single dose randomized 
controlled 28 +/- 4 day trial to study the effect of delayed (ileocolonic)-release ox bile extract 500 mg bid on 
postprandial glycemia, insulin sensitivity, fasting and postprandial incretins (FGF-19, GLP-1, OXM, PYY3-36), 
gastric emptying and weight loss in overweight or obese type 2 diabetic subjects receiving therapy with DPP4 
inhibitors (e.g. sitagliptin) alone or in combination with metformin. 
D.3. Participants: Subjects with obesity and T2DM on therapy with DPP4 inhibitors (e.g. sitagliptin) alone or in 
combination with metformin (standard of care) will be recruited by direct contact from an established database 
of patients with T2DM and BMI >30 kg/m2 or by public advertisement.  Eligible cases will be invited to 
participate by letter using the randomization scheme provided by the study bio-statistician. All subjects will be 
given a verbal explanation of the study, provided time to read and study the written consent form and its 
information, given opportunities to ask questions and a copy of the consent form.  Participants will be informed 
of their right to withdraw from the study at any time without prejudice to their clinical management now or in the 
future. Consent will be sought by one of the medical doctor investigators or study coordinator, and consent will 
be documented by the participant’s signature on the consent form. All recruitment or contact information will be 
approved by Mayo's Institutional Review Board. 
The inclusion criteria includes:  
a) Overweight or obese subjects with BMI> 30 kg/m2 with type 2 diabetes mellitus taking DPP4 inhibitors 
(e.g. sitagliptin) alone or in combination with metformin, standard of care for type 2 DM. 
b) Age: 18-70 years; 


- 3 - 
 
c) Gender: men or women. Women of childbearing potential will have a negative pregnancy test before 
initiation of medication and within 48 hours of receiving radioisotope for the gastric emptying study.   
The exclusion criteria includes:  
a) Structural or metabolic diseases/conditions that affect the gastrointestinal system, or functional 
gastrointestinal disorders. For screening the bowel disease questionnaire will be used to exclude 
subjects with irritable bowel syndrome;  
b) Subjects with stool type Bristol classification 4-7 per bowel disease questionnaire (bdq);  
c) To ensure homogeneity between treatment groups we will exclude subjects with other treatment for 
t2dm and with HbA1c > 8% and/or fasting glucose >250 mg/dl. If an HbA1c has not been completed 
within 3 months of the screening visit, one will be done at the screening visit. 
d) Female subjects who are pregnant or breast-feeding;  
e) Concomitant use of appetite suppressants or orlistat or phentermine-topiramate ER or lorcaserin. 
f)  Individuals who are currently on treatment for cardiac, pulmonary, gastrointestinal, hepatic, renal, 
hematological, neurological, endocrine (other than t2dm) and unstable psychiatric disease;  
  
D.4. Study Medication –24 overweight or obese type-2 diabetic adults on therapy DPP4 inhibitors (e.g. 
sitagliptin) alone or in combination with metformin  will be randomized: 12 subjects to delayed (ileocolonic)-
release ox bile extract daily and 12 subjects for matched-placebo (PO tablet twice daily) for 28 +/- 4 days. 
Medication will be provided by Satiogen.  Subjects will take medication or placebo daily, 30 minutes prior to 
breakfast and evening dinner, for 28 +/- 4 days. 
D5.  Screening and baseline evaluations: After obtaining written informed consent, a medical history, 
physical exam,  vital signs (pulse, blood pressure, respiration rate and temperature), height, weight, waist and 
hip circumference measurements, HbA1c (if not completed within 3 months) and filling out the following 
questionnaires, if the study participants have passed their screening evaluation, they will present themselves at 
the Clinical Research and Trials Unit (CRTU)in the Charlton Building on the 7th floor at Mayo Clinic in 
Rochester, MN.  
The screening questionnaires consist of the  
1) GI Screening Bowel Disease Questionnaire,  
2) the Hospital Anxiety and Depression Inventory,  
3) the Bristol stool scale, 
4) the Physical Activity Questionnaire,  
5) the Eating Patterns Questionnaire,  
6) the Body Self Relations Questionnaire,  
7) the Audit C Questionnaire and  
8) the Weight Management Questionnaire.  
We will obtain a fasting glucose level at screening.  
We will also do solid and liquid gastric emptying and a mixed meal glucose tolerance test at baseline and on 
day 28th (+/- 4 days) after treatment. Baseline and Treatment vital signs, weight and waist and hip 
measurements will be taken. At day 28 (+/- 4 days), we will conduct investigation of glycemia, insulin sensitivity 
in response to a mixed meal.  A negative urine pregnancy test is required for women of child-bearing potential 
48 hours prior to radioisotope exposure in the gastric emptying tests. 
See appendix A: Questionnaires 
D.6. Endpoints for Analysis:  
The primary endpoints for analysis will be:  
a) Reduction in area above basal (AAB) for Fasting Glucose.   
The secondary endpoints will be:  
a) Fasting glucose;  
b) Insulin sensitivity calculated by the oral minimal model;  
c) Weight change, kg;  
d) Insulin secretion calculated by the oral minimal model;  
e) Area under the curve of GLP-1, PYY3-36, OXM, and FGF-19;  
f)  Change in fasting Adiponectin, Leptin, DPP-IV,  
g) Change in gastric emptying rates at 1, 2, and 4 hours along with gastric half-emptying times.  
 
E. Materials and Methods 


- 4 - 
 
E.1. Delayed (ileocolonic)-release Ox Bile.  After acquiring ox bile extract 500 mg tablets from Satiogen, 
tablets and matched placebo controls will be encapsulated in enteric coating formulated  by Avomeen 
Analytical Services, Ann Arbor MI  Subjects will take medication or matched placebo orally twice daily on an 
empty stomach, 30 minutes prior to breakfast and evening dinner for 28 +/- 4 days. 
E.2. Mixed Oral Glucose Tolerance Test and meal (mixed meal) gastric emptying test: The mixed meal 
will be done at baseline and on day 28 (+/- 4 days) after a 10 to 12 hours fasting.  Subjects will report to the 
Mayo Clinic CRTU Charlton 7 at the scheduled appointment time.  After arrival to the CRTU, an 18 g cannula 
will be inserted retrogradely into a peripheral arm or hand vein.  At baseline testing, participants will receive a 
63g glucose in 240 ml of skim milk and a meal with 2 scrambled eggs, 50g of Canadian Bacon and one slice of 
bread (~560 Kcal: 43% carbohydrate, 18% protein, and 40% fat). To enable measurement of the solid and 
liquid phase of gastric emptying, the milk will be labeled with 0.5 mCi of 99mTc DTPA and the egg will be 
labeled with 0.05 mCi of In111Chloride labeled activated charcoal to allow for measurement of gastric emptying 
and orocecal transit 22,23,24.  Scans will be acquired at the completion of the meal and every 15 minutes for the 
first 2 hours and then at 150, 180, 210, 240, and 360 minutes following the meal.  In addition, following the 
mixed meal, blood samples will be collected at -30,-15, 0, 10, 20, 30, 45, 60, 90, 120, 180, 240, 300, and 360 
min for measurement of plasma glucose, insulin and C-peptide concentration. The results from the mixed meal 
will be used to calculate the area above basal (AAB) for glucose, and the oral minimal model to calculate the 
Insulin Sensitivity (IS) 18. Other methods for calculating the IS will be considered 19 20.  At the conclusion of 
testing, the cannula will be removed and the subject will be dismissed from the CRTU. 
 
On Day 28 (+/- 4 days), subjects will repeat gastric emptying and mixed meal testing as described above but 
will receive the study medication/placebo 30 minutes prior to the test meal. 
E.3. Blood samples: The fasting blood samples will be collected during the mixed meal and stored -70° C 
freezer. We will analyze plasma glucose, insulin, C-peptide, GLP-1, PYY3-36, OXM, FGF-19, DPP-4, 7-α-C4, 
Adiponectin, Leptin, CCK, PP. 
 
                                                                          
 
 
 
 
 
 
 
F. Statistical Analysis    
The primary analyses will compare treatment groups at the post–4-week treatment visit using analysis of 
covariance (ANCOVA) models incorporating the corresponding baseline study value as a covariate (e.g., 
fasting or peak concentration, or AAB).  
F.1.Sample size assessment - The table below summarizes data for primary response measures and uses 
the (relative variation, CV%) to estimate the effect size detectable with 80% power based on a two sample t-
test at a two-sided α level of 0.05. The effect size is the difference in group means as a percentage of the 
listed mean for each response and assumes 12 subjects per group; these effect sizes are clinically significant. 
The ANCOVA analysis will likely provide similar power for somewhat smaller differences by incorporating 
relevant covariates. The data for AUC for glucose and insulin have been published25. Groups will be balance 
based on the use of gliptins and/or metformin.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assuming n=12 per group 
Mean 
SD 
CV% 
Effect Size (%) 
[delta units] 80% Power   
    Δ/SD 
Response Type 
AAB for Glucose (mmol/6hr) 
3247 
591  
18%    22 (%) [703 mmol/6h]        
 1.2 
Solid (egg meal) gastric emptying t1/2(min) 
 117 
 34.7 
30% 
36 (%) [42 mins]           
1.2 
 
G. Potential Pitfalls and Precautions Taken 
G.1. Potential pitfalls of minor significance in this study are: a) Selection bias - Participants willing to 
participate will likely be more motivated to lose weight. Randomization, double blind will avoid any selection 
Screen 
Visit 
Within  
2 weeks 
      VISIT: 1 
Baseline  
Glucose Tolerance & 
Gastric Emptying tests 
(Blood samples) 
  3 
Day 1 
   2 
Day 28+/-4 
Treatment  
Glucose Tolerance &  
Gastric Emptying tests 
(Blood samples) 
Treatment  
with Ox Bile 


- 5 - 
 
bias; b) Potential for type II error - The sample sizes have been based on appropriate statistical power for 
OGTT, glucose and insulin AUC endpoints for which the coefficient of variation has been thoroughly 
characterized in the prior literature from our lab; and c) Feasibility - We have already identified a cohort of 
people in our community who are type 2 Diabetics and willing to participate. We have the experience to 
successfully recruit 50 type 2 diabetics for the three days of testing in the CRTU.   
G.2.Human Studies Aspects  
G.2.a. Adverse Effects of Medications: Ox bile extract is used for gallbladder stones dissolution and 
prevention as a nutraceutical and food supplement. It is associated with the following potential adverse effects: 
nausea, diarrhea, anorexia, hypersensitivity.  These are included in the consent form. 
G.2.b. Radiation exposure: in this study comes from the 99mTc and 111In used to measure gut transit. 
These exposures conform to previously approved levels of radiation exposure approved by the Radiation 
Control Committee at Mayo Clinic. The radiation dosimetry and organ exposures (in mrad) are minimal.  
See appendix B: Dosimetry Table 
 
G.2.c Patient risks: If the fasting glucose is greater than 250 mg/dl on either testing day, subject will 
be managed following standard of care in clinical setting. The recommended insulin doses will be per “Insulin 
sliding scale with Insulin regular: Glucose 250-259 = 3 units; 260-299 = 4 units; 300-339 = 5 units; 340-379 = 6 
units; 380-399 = 7 units; >400 = call physician. Likely this subject will be excluded from the analysis.  
 
 
H. Anticipated Results and Significance   
We expect to demonstrate that delayed (ileocolonic)-release ox bile extract increases insulin sensitivity or 
reduces insulin resistance, improving glycemic control. This study will provide the basis for future 
pharmacological studies, exploring the effect of ox bile extract delayed (ileocolonic)-release on type 2 DM and 
obesity in a placebo-controlled 12 week randomized controlled trial.  


- 6 - 
 
References  
1 
Low S, Chin MC, Deurenberg-Yap M. Review on epidemic of obesity. Ann Acad Med Singapore 2009;38:57-9. 
2 
Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology 2007;132:2087-
102. 
3 
Cleeman JI, Grundy SM, Becker D, et al. Executive summary of the Third Report of the National Cholesterol 
Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults 
(Adult Treatment Panel III). Jama-J Am Med Assoc 2001;285:2486-97. 
4 
Yach D, Stuckler D, Brownell KD. Epidemiologic and economic consequences of the global epidemics of obesity 
and diabetes. Nature medicine 2006;12:62-6. 
5 
Tsai AG, Wadden TA. Obesity. Annals of internal medicine 2013;159:ITC3-1. 
6 
Pournaras D, Glicksman C, Vincent R, et al. The role of bile after Roux-en-Y gastric bypass in promoting weight 
loss and improving glycaemic control. Endocrinology 2012;153:3613-9. 
7 
Kohli R, Bradley D, Setchell K, Eagon J, Abumrad N, Klein S. Weight Loss Induced by Roux-en-Y Gastric Bypass But 
Not Laparoscopic Adjustable Gastric Banding Increases Circulating Bile Acids. The Journal of clinical endocrinology and 
metabolism 2013;98:12. 
8 
Kohli R, Kirby M, Setchell K, et al. Intestinal adaptation after ileal interposition surgery increases bile acid 
recycling and protects against obesity-related comorbidities. American journal of physiology. Gastrointestinal and liver 
physiology 2010;299:60. 
9 
Kohli R, Setchell K, Kirby M, et al. A Surgical Model in Male Obese Rats Uncovers Protective Effects of Bile Acids 
Post-Bariatric Surgery. Endocrinology 2013. 
10 
Wu T, Bound M, Standfield S, Jones K, Horowitz M, Rayner C. Effects of Taurocholic Acid on Glycemic, Glucagon-
like Peptide-1, and Insulin Responses to Small Intestinal Glucose Infusion in Healthy Humans. The Journal of clinical 
endocrinology and metabolism 2013;98:22. 
11 
Kars M, Yang L, Gregor M, et al. Tauroursodeoxycholic Acid may improve liver and muscle but not adipose tissue 
insulin sensitivity in obese men and women. Diabetes 2010;59:1899-905. 
12 
Buchwald H, Ikramuddin S, Dorman RB, Schone JL, Dixon JB. Management of the metabolic/bariatric surgery 
patient. Am J Med 2011;124:1099-105. 
13 
Xie Q, Khaoustov V, Chung C, et al. Effect of tauroursodeoxycholic acid on endoplasmic reticulum stress-induced 
caspase-12 activation. Hepatology (Baltimore, Md.) 2002;36:592-601. 
14 
Ozcan U, Yilmaz E, Ozcan L, et al. Chemical chaperones reduce ER stress and restore glucose homeostasis in a 
mouse model of type 2 diabetes. Science (New York, N.Y.) 2006;313:1137-40. 
15 
Odunsi-Shiyanbade ST, Camilleri M, McKinzie S, et al. Effects of chenodeoxycholate and a bile acid sequestrant, 
colesevelam, on intestinal transit and bowel function. Clin Gastroenterol Hepatol 2010;8:159-65. 
117 
Iguchi Y, Nishimaki-Mogami T, Yamaguchi M, Teraoka F, Kaneko T, Une M. Effects of chemical modification of 
ursodeoxycholic acid on TGR5 activation. Biol Pharm Bull 2011;34:1-7. 
18 
Cobelli C, Toffolo G, Dalla Man C, et al. Assessment of beta-cell function in humans, simultaneously with insulin 
sensitivity and hepatic extraction, from intravenous and oral glucose tests. American journal of physiology. 
Endocrinology and metabolism 2007;293. 
19 
Abdul-Ghani MA, Matsuda M, Balas B, DeFronzo RA. Muscle and liver insulin resistance indexes derived from the 
oral glucose tolerance test. Diabetes Care 2007;30:89-94. 
20 
Matsuda M, DeFronzo RA. Insulin sensitivity indices obtained from oral glucose tolerance testing: comparison 
with the euglycemic insulin clamp. Diabetes Care 1999;22:1462-70. 
21 
Camilleri M, Iturrino J, Bharucha AE, et al. Performance characteristics of scintigraphic measurement of gastric 
emptying of solids in healthy participants. Neurogastroenterology and motility : the official journal of the European 
Gastrointestinal Motility Society 2012. 
22 
Camilleri M, Brown M, Malagelada J. Impaired transit of chyme in chronic intestinal pseudoobstruction. 
Correction by cisapride. Gastroenterology 1986;91:619-26. 
23 
Vazquez Roque MI, Camilleri M, Stephens DA, et al. Gastric sensorimotor functions and hormone profile in 
normal weight, overweight, and obese people. Gastroenterology 2006;131:1717-24. 
24 
Cremonini F, Mullan BP, Camilleri M, Burton DD, Rank MR. Performance characteristics of scintigraphic transit 
measurements for studies of experimental therapies. Aliment Pharmacol Ther 2002;16:1781-90. 
25 
Smushkin G, Sathananthan M, Piccinini F, et al. The effect of a bile acid sequestrant on glucose metabolism in 
subjects with type 2 diabetes. Diabetes 2013;62:1094-101. 


- 0 - 
 
Appendix A: Questionnaires 
Bowel Disease Questionnaire 
 
In the past 12 months, have you experienced the following? 
QUESTION 
YES 
NO 
1. 2 or less than 2 bowel movements/week 
 
 
2. Excessive straining or sensation of incomplete evacuation of stool on 
more than 25% of occasions 
 
 
3. Lumpy stools on more than 25% of occasions 
 
 
At least 3 months of continuous or recurrent symptoms of: 
4. Abdominal pain or discomfort relieved by defecation 
5. Abdominal pain or discomfort associated with a change in stool frequency 
6. Abdominal pain or discomfort associated with a change in stool consistency 
 
 
 
 
 
 
7. More than 3 bowel movements per day 
 
 
8. Loose watery stools 
 
 
9. Bloating 
 
 
10. Swallowing difficulties 
 
 
11. Upper abdominal pain after meals more than once a month 
 
 
12. Abdominal bloating after meals 
 
 
13. Nausea regularly more than once a month 
 
 
14. Vomiting regularly more than once a month 
 
 
15. Heartburn regularly more than once a week 
 
 
16. Acid reflux regularly more than once a week 
 
 
 
Sign_________________________________ Date _______________ 
 
 
 


- 1 - 
 
The Hospital Anxiety and Depression Questionnaire 
 
Please read each item and circle the reply which best describes how you have been feeling during the past 
week.  Don’t devote too much time to your responses; your immediate reaction will probably be more accurate 
than a long thought out response. 
 
1. I feel tense or ‘wound up’ : 
Most of the time 
A lot of the time 
Occasionally 
Not at all 
 
2. I still enjoy the things I used to enjoy : 
Definitely as much 
Not quite so much 
Only a little  
Hardly at all 
 
3. I get a frightened feeling, as if something awful is about to happen : 
Very definitely and quite badly 
Yes, but not too badly 
A little, but it doesn’t worry me 
Not at all 
 
4. I can laugh and see the funny side of things : 
As much as I always could 
Not quite so much now 
Definitely not so much now 
Not at all 
 
5. Worrying thoughts go through my mind : 
A great deal of the time 
A lot of the time 
From time to time 
Only occasionally 
 
6. I feel cheerful : 
Not at all 
Not often 
Sometimes 
Most of the time 
 
7. I can sit at ease and feel relaxed : 
Definitely 
Usually 
Not often 
Not at all 


- 2 - 
 
 
8. I feel as if I am slowed down : 
Nearly all the time 
Very often 
Sometimes 
Not at all 
 
9. I get a frightened feeling, like ‘butterflies in the stomach’ : 
Not at all  
Occasionally 
Quite often 
Very often 
 
10.  I have lost interest in my appearance : 
Definitely 
I don’t take as much care as I should 
I may not take quite as much care 
I take just as much care as ever 
 
11. I feel restless as if I have to be on the move : 
Very much indeed 
Quite a lot 
Not very much 
Not at all 
 
12. I look forward with enjoyment to things : 
As much as I ever did 
Rather less than I used to 
Definitely less than I used to 
Hardly at all 
 
13. I get sudden feelings of panic : 
Very often indeed 
Quite often 
Not very often 
Not at all 
 
14. I can enjoy a good book or TV program : 
Often 
Sometimes 
Not often 
Very seldom 
 
 
Sign___________________________________ Date _______________ 
 


- 3 - 
 
Bristol Stool Scale 
Circle the form which best describes your normal bowel movements. 
Ease of Passage: 
 1.  Manual disimpaction required 
 2.  Enema or suppository required to initiate bowel movement 
 3.  Some straining necessary to pass bowel movement 
 4.  Easy normal passage of stool without straining 
 5.  Urgent need to pass bowel movement spontaneously; no abdominal pain or discomfort present 
 6.  Urgent need to pass bowel movement spontaneously; abdominal pain or cramping present 
 7.  Incontinent of bowel movements 
 
 


- 4 - 
 
Physical Activity Stages of Change Questionnaire 
 
For each of the questions below, please check Yes or No.  Please be sure to follow the instructions 
carefully. 
 
Physical activity or exercise includes activities such as walking briskly, jogging, bicycling, swimming or any 
other activity where the exertion is as least as hard as these activities.  Your heart rate and breathing should 
increase. 
 
NO 
YES 
1. I am currently physically active 
 
 
2. I intend to become more physically active in the next 6 months 
 
 
 
For activity to be regular, it must add up to a total of 30 minutes or more per day, and be done at least 5 
days per week.  For example, you could take one 30 minute walk, or take three 10 minute walks each day.   
 
 
NO 
YES 
3. I currently engage in regular physical activity 
 
 
4. I  have been regularly physically active for the past 6 months 
 
 
 
 
 
Sign_________________________________ Date _______________ 
 
 
 
 
 


- 5 - 
 
Eating Patterns Questionnaire 
 
 
 
 
__ 15 
1. During the past six months, did you often eat within any two-hour period what most people would 
regard as an unusually large amount of food? 
1
  Yes                0
 No  → SKIP TO QUESTION 5 
 
 
 
__ 16 
2. During the times when you ate this way, did you often feel you couldn’t stop eating or control what 
or how much you were eating?  
1
  Yes                0
 No  → SKIP TO QUESTION 5 
 
3. During the past six months, how often, on average, did you have times when you ate this way – that 
is, large amounts of food plus the feeling that your eating was out of control (there may have been 
some weeks when it was not present – just average those in).  
__ 17 
1
 Less than one day a week 
2
 One day a week 
     3
 Two or three days a week 
4
 Four to five times a week 
5
 Nearly every day 
 
4.  Did you usually have any of the following experiences during these occasions? 
__ 18 
a.  Eating much more rapidly than usual?                      1
  Yes                0
 No   
__ 19 
b.  Eating until you felt uncomfortably full?                 1
  Yes                0
 No   
 
__ 20 
c.  Eating large amounts of food when you didn’t 
feel physically hungry?                                                       1
  Yes                0
 No   
 
__ 21 
d.  Eating alone because you were embarrassed 
     by how much you were eating?                                       1
  Yes                0
 No   
 
__ 22 
e.  Feeling disgusted with yourself, depressed, 
     or feeling very guilty after overeating?                        1
  Yes                0
 No   
 
5.  In general, during the past six months, how upset were you by overeating (eating more than you 
think is best for you)? 
__ 23 
1
 Not at all 
2
 Slightly 
     3
 Moderately 
4
 Greatly 
5
 Extremely 
 
6.  In general, during the past six months, how upset were you by the feeling that you couldn’t stop 
eating or control what or how much you were eating? 
__ 24 
1
 Not at all 
2
 Slightly 
     3
 Moderately 
4
 Greatly 
5
 Extremely 
 
 
7.  During the past six months, how important has your weight or shape been, in how you feel about or 
evaluate yourself as a person – as compared to other aspects of your life, such as how you do at 
work as a parent, or how you get along with other people? 


- 6 - 
 
__ 25 
1
 Weight and shape were not very important 
2
 Weight and shape played a part in how you felt about yourself 
3
 Weight and shape were among the main things that affected how you felt about yourself 
4
 Weight and shape were the most important things that affected how you felt about 
yourself 
 
8.  During the past three months, did you ever make yourself vomit in order to avoid gaining weight 
after binge eating? 
__ 26 
__ 27 
1
 Yes → 
0
 No   
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 More than five times a week 
 
 
 
 
9.  During the past three months, did you ever take more than twice the recommended dose of 
laxatives in order to avoid gaining weight after binge eating? 
__ 27 
__ 28 
1
 Yes → 
0
 No   
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 More than five times a week 
 
 
 
 
10.  During the past three months, did you ever take more than twice the recommended dose of 
diuretics (water pills) in order to avoid gaining weight after binge eating? 
__ 29 
__ 30 
1
 Yes → 
0
 No   
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 More than five times a week 
 
 
 
 
 
11.  During the past three months, did you ever fast – not eat anything at all for at least 24 hours --in 
order to avoid gaining weight after binge eating? 
__ 31 
__ 32 
1
 Yes → 
0
 No   
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 Nearly every day 
 


- 7 - 
 
 
 
 
12.  During the past three months, did you ever exercise for more than an hour specifically in order to 
avoid gaining weight after binge eating? 
__ 33 
__ 34 
1
 Yes → 
0
 No   
 
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 More than five times a week 
 
 
 
 
13.  During the past three months, did you ever take more than twice the recommended dose of a diet 
pill in order to avoid gaining weight after binge eating? 
__ 35 
__ 36 
1
 Yes → 
0
 No   
 
 
 
How often, on average, was that? 
1
 Less than one day a week 
2
 One day a week 
3
 Two or three days a week 
4
 Four to five times a week 
5
 More than five times a week 
 
 
 
 
 
 
 
 
 
Sign____________________________________ Date _________________ 
 
 
 
 
 
 
 
 
 
 
 


- 8 - 
 
 
 
Multi-dimensional Body-Self Relations Questionnaire (MBSRQ) 
 
 
On a scale of 1 (very dissatisfied) to 5 (very satisfied) please indicate how  
satisfied you are with each of the following areas or aspects of your body: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Very 
dissatisfied 
Mostly 
dissatisfied 
Neither 
satisfied 
nor 
dissatisfied 
 
Mostly 
satisfied 
Very 
satisfied 
  
1. Face (facial features, complexion) 
 
1
 
2
 
3
 
4
 
5
 
  
2. Hair (color, thickness, texture) 
 
1
 
2
 
3
 
4
 
5
 
 
3  Lower torso (buttocks, hips, thighs, legs) 
 
1
 
2
 
3
 
4
 
5
 
 
4. Mid torso (waist, stomach) 
 
1
 
2
 
3
 
4
 
5
 
 
5. Upper torso (chest or breasts, shoulders, 
arms) 
 
1
 
2
 
3
 
4
 
5
 
 
6.  Muscle tone 
 
1
 
2
 
3
 
4
 
5
 
 
7. Weight 
 
1
 
2
 
3
 
4
 
5
 
 
8. Height 
 
1
 
2
 
3
 
4
 
5
 
 
9. Overall appearance 
 
1
 
2
 
3
 
4
 
5
 
 
 
 
Sign____________________________________ Date _________________ 
 
 
 
 


- 9 - 
 
Page 1 


- 10 - 
 
 


- 11 - 
 
 


- 12 - 
 
 


- 13 - 
 
 


- 14 - 
 
Appendix B: Dosimetry per administration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


- 15 - 
 
Sample Bowel Diary: Predose to Day 5: 
Effect of Delayed-Release Bile Acid on Insulin Sensitivity, 
Gastric Emptying and Body Weight in Overweight or Obese 
Patients with Type 2 Diabetes Mellitus 
IRB # 15-007765 
 
 
Bowel Habit Diary 
 
Predose and through Day 5 
Of study medication/placebo 
 
 
 
 
Dates:_______________  to ________________ 
 
 
 
 
Andres Acosta Cardenas, MD, 
Principal Investigator 
 
Sara Linker Nord, LPN 
Pager: 507- 538-2479 
Phone: 507-266-1999 
 
 
 
 
 
 


- 16 - 
 
Daily Diary
Date_______________________
No Bowel Movements today.
Study #____________________
1
hard lumps
1
Manual Disimpaction
1
no
2
lumpy sausage
2
Enema needed
2
yes
3
cracked sausage
3
Straining needed
4
smooth sausage
4
Normal
5
soft lumps
5
Urgent w o/pain
6
Mushy
6
Urgent w /pain
7
w atery
7
Incontinent
am
1
pm
am
2
pm
am
3
pm
am
4
pm
am
5
pm
am
6
pm
am
7
pm
No
Yes
(complete below)
Event
Mild  /  Moderate  /  Severe
 
Resolved  /  Ongoing
Event
Mild  /  Moderate  /  Severe
 
Resolved  /  Ongoing
No
Yes
(complete below)
Medication
Medication
Medication
Dose
Dose
Dose
Time
Time
Time
Have you taken any medications other than those you routinely use 
today?
Did you feel like you 
completely emptied your 
bowels?
hr.
min
hr.
hr.
min
min
Describe the Ease of 
Passage of bowel 
movement
Describe the 
consistency of bowel 
movement
Have you had any unusual negative events today?
hr.
hr.
min
min
hr.
min
hr.
min
 


- 17 - 
 
Sample Postdose Diary: 
Effect of Delayed-Release Bile Acid on Insulin Sensitivity, 
Gastric Emptying and Body Weight in Overweight or Obese 
Patients with Type 2 Diabetes Mellitus 
IRB # 15-007765 
 
 
Bowel Habit Diary 
 
 
Final 5 Days  
Of study medication/placebo 
 
 
 
 
Dates:_______________  to ________________ 
 
 
 
 
Andres Acosta Cardenas, MD, 
Principal Investigator 
 
Sara Linker Nord, LPN 
Pager: 507- 538-2479 
Phone: 507-266-1999 
 
 
 
 


- 18 - 
 
Daily Diary
Date_______________________
No Bowel Movements today.
Study #____________________
Dose 1: ____:____AM
Dose 2: ____:____PM
1
hard lumps
1
Manual Disimpaction
1
no
2
lumpy sausage
2
Enema needed
2
yes
3
cracked sausage
3
Straining needed
4
smooth sausage
4
Normal
5
soft lumps
5
Urgent w o/pain
6
Mushy
6
Urgent w /pain
7
w atery
7
Incontinent
am
1
pm
am
2
pm
am
3
pm
am
4
pm
am
5
pm
am
6
pm
am
7
pm
No
Yes
(complete below)
Event
Mild  /  Moderate  /  Severe
 
Resolved  /  Ongoing
Event
Mild  /  Moderate  /  Severe
 
Resolved  /  Ongoing
No
Yes
(complete below)
Medication
Medication
Medication
Dose
Dose
Dose
Time
Time
Time
Take one (1) Tablet twice a day: 30 minutes before Breakfast and 30 minutes before Dinner.
Have you taken any medications other than those you routinely use 
today?
Did you feel like you 
completely emptied your 
bowels?
hr.
min
hr.
hr.
min
min
Describe the Ease of 
Passage of bowel 
movement
Describe the 
consistency of bowel 
movement
Have you had any unusual negative events today?
hr.
hr.
min
min
hr.
min
hr.
min