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Trial registered on ANZCTR


Registration number
ACTRN12620000611921p
Ethics application status
Submitted, not yet approved
Date submitted
28/11/2019
Date registered
25/05/2020
Date last updated
25/05/2020
Date data sharing statement initially provided
25/05/2020
Type of registration
Prospectively registered

Titles & IDs
Public title
The effect of mediterranean diet on the microbes community and immune response in fatty liver disease.
Scientific title
The effect of Mediterranean Diet on the Microbiome and Immune Response in NAFLD Related Liver Disease

Secondary ID [1] 299948 0
Nil known
Universal Trial Number (UTN)
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Non alcoholic fatty liver disease 315398 0
Hepatocellular carcinoma 315399 0
Condition category
Condition code
Oral and Gastrointestinal 313693 313693 0 0
Other diseases of the mouth, teeth, oesophagus, digestive system including liver and colon
Cancer 313694 313694 0 0
Liver
Diet and Nutrition 313695 313695 0 0
Obesity

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Participants will receive Mediterranean diet consisting of 5 meals/day (3 main meals and two snacks) for 12 weeks. The Mediterranean diet is a plant-based diet rich in polyunsaturated fats, fibre, polyphenols, vitamins and carotenoids, with low red meats consumption and increase of fish.

An example of breakfast is Greek yogurt with sliced fruits and oats, An example of lunch is Whole-grain sandwich with grilled vegetables, such as eggplant, zucchini, bell pepper, and onion, with fruit for dessert. An example of dinner is whole-grain pasta with tomato sauce, olive oil, and grilled vegetables. Examples of snacks include a small serving of nuts, whole fruits, dried fruit, or a small serving of yogurt.

No drinks are provided or prescribed as part of this intervention - patients will be encouraged to drink water. Tea and Coffee is acceptable as well.

Participants will be provided with a food diary - they will make note of any meals provided they did not consume, or foods consumed that were outside of their meal plan.
Intervention code [1] 316216 0
Lifestyle
Intervention code [2] 316217 0
Behaviour
Comparator / control treatment
This research team will intentionally recruit people with previous diagnosis of liver disease (NAFLD and NAFLD-related HCC) and their respective household. The healthy household participant will be used as control and they will also receive mediterranean diet for the same period.
Control group
Active

Outcomes
Primary outcome [1] 322123 0
The gut microbiome assessed by 16S RNA sequencing of stool samples.
Timepoint [1] 322123 0
The primary outcome is assessed at Baseline, 6 weeks and 12 weeks. The primary timepoint will be 12 weeks.
Primary outcome [2] 322124 0
The immune response assessed by flow cytometry to profile white blood cells.
Timepoint [2] 322124 0
The primary outcome is assessed at Baseline, 6 weeks and 12 weeks. The primary timepoint will be 12 weeks.
Secondary outcome [1] 377429 0
The body composition assessed by Biometric Impedance Analysis.
Timepoint [1] 377429 0
The secondary outcome is assessed at Baseline, 6 weeks and 12 weeks. The secondary timepoint will be 12 weeks.
Secondary outcome [2] 377430 0
Change in blood lipid levels assessed by serum assay of blood samples taken.
Timepoint [2] 377430 0
The secondary outcome is assessed at Baseline, 6 weeks and 12 weeks. The secondary timepoint will be 12 weeks.
Secondary outcome [3] 377431 0
Quality of life assessed by SF36 questionnaire (The Short Form Health Survey).
Timepoint [3] 377431 0
This secondary outcome is assessed at Baseline and 12 weeks. The secondary timepoint will be 12 weeks.
Secondary outcome [4] 382567 0
Change in blood glucose level assessed by serum assay of blood samples taken.
Timepoint [4] 382567 0
The secondary outcome is assessed at Baseline, 6 weeks and 12 weeks. The secondary timepoint will be 12 weeks.
Secondary outcome [5] 382568 0
Change in blood insulin level assessed by serum assay of blood samples taken.
Timepoint [5] 382568 0
The secondary outcome is assessed at Baseline, 6 weeks and 12 weeks. The secondary timepoint will be 12 weeks.
Secondary outcome [6] 382569 0
Change in blood liver function test levels assessed by serum assay of blood samples taken.
Timepoint [6] 382569 0
The secondary outcome is assessed at Baseline, 6 weeks and 12 weeks. The secondary timepoint will be 12 weeks.

Eligibility
Key inclusion criteria
1. Patients with well compensated, Child Pugh A, NAFLD related liver cirrhosis, including those who have undergone resection for HCC.
2. Patients under the care of the investigators of this study (or their associates) who routinely visit study sites for treatment or care
3. Patients willing to provide informed consent
4. Participants must be motivated to eat pre-prepared foods for 12 weeks
5. Participant is aged between 18-75 years old
6. Participant is willing and able to provide a stool, urine, blood and oral sample for this study
7. Participant has not taken any antibiotic medication within the past 3 months

For control group: Participant is part of the same household than patient recruited and presenting good health
Minimum age
18 Years
Maximum age
75 Years
Gender
Both males and females
Can healthy volunteers participate?
Yes
Key exclusion criteria
1. Participant unwilling or unable to provide informed consent
2. Patient with clinical or biochemical evidence of portal hypertension
3. Patients with other causes of liver disease, not NAFLD related including alcoholic liver disease and viral hepatitis
4. Participant who has taken any antibiotic medication within the past 3 months
5. Participant with diagnosed food allergy or intolerance
6. Participant is pregnant or breastfeeding
7. Participant has received nutritional counselling in the previous 3 months
8. Participants have medical, religious, or cultural dietary restrictions that would preclude their eating a Mediterranean diet

Study design
Purpose of the study
Treatment
Allocation to intervention
Non-randomised trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?



Intervention assignment
Parallel
Other design features
Phase
Not Applicable
Type of endpoint(s)
Efficacy
Statistical methods / analysis
Based on previous publications and our data (unpublished) on the microbiome diversity in liver disease, a sample size between 12 and 18 per intervention group is recommended to identify a difference of 15% in alpha-diversity (Shannon index) between groups. The effect size d is 1.0974, alpha-error probability of 5% and beta-error of 20%. We aim to recruit 60 participants, being 15 with NAFLD, 15 with NAFLD-HCC and their respective household matched healthy controls.
Statistical analysis will be performed by a researcher with consultation and advice from biomedical statistician.
Bioinformatic analysis will be undertaken using custom in-house pipelines which employ well-established software packages for metagenomic analysis (e.g, Kraken and MetaPhAn2 for compositional/profiling and HUMANn2 and SUPER-FOCUS for functional assignment). All data will be stored in numerical format which can then be used for statistical analysis. Microbiome perturbations will be evaluated using approaches specific to next generation sequencing data analysis. Univariate analysis will be used to assess both differences in functional and taxonomic signatures specific to disease status and variations in alpha diversity between treatment groups. Concurrently, multivariant analysis e.g. permutational multivariate analysis of variance (PERMANOVA) will quantify multivariate community-level differences between groups. In addition to this several approaches will be used to define microbiome/metabolome correlations with health indices including cluster-based analysis, correlations and regression analysis. All statistical analysis will be implemented in R using both a multitude of general statistical and microbiome specific packages (e.g. stats, Hmisc, vegan, coin, phyloseq, metagenomeSeq and data visualisation packages such as ggplot2.

Recruitment
Recruitment status
Not yet recruiting
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
NSW
Recruitment hospital [1] 15356 0
St George Hospital - Kogarah
Recruitment postcode(s) [1] 28672 0
2217 - Kogarah

Funding & Sponsors
Funding source category [1] 304411 0
Charities/Societies/Foundations
Name [1] 304411 0
Glenn Family Foundation
Address [1] 304411 0
Balgowlah Heights, NSW
Australia
2093
Country [1] 304411 0
Australia
Primary sponsor type
University
Name
UNSW Sydney
Address
Microbiome Research Centre - MRC
Level 2, Research & Education Building
4-10 South Street, Kogarah, NSW, 2217
Country
Australia
Secondary sponsor category [1] 305872 0
None
Name [1] 305872 0
Address [1] 305872 0
Country [1] 305872 0

Ethics approval
Ethics application status
Submitted, not yet approved
Ethics committee name [1] 304845 0
South Eastern Sydney Local Health District Human Research Ethics Committee
Ethics committee address [1] 304845 0
Prince of Wales Hospital
G71 East Wing, Edmund Blacket Building
Randwick, NSW, 2031
Ethics committee country [1] 304845 0
Australia
Date submitted for ethics approval [1] 304845 0
29/11/2019
Approval date [1] 304845 0
Ethics approval number [1] 304845 0

Summary
Brief summary
The purpose of this study is to see how the microbial community and immune system in people with liver disease responds to a Mediterranean diet.

Who is it for?
You may be eligible for this study if you or a member of your immediate (household) family have fatty liver disease, including liver cancer.

Study details
All participants in this study will be provided with 5 meals a day of the Mediterranean diet. This includes 3 main meals and two snacks. The Mediterranean diet is rich in polyunsaturated fats, fibres, polyphenols, vitamins and carotenoids. As part of this study, participants will provide stool, urine, blood and mouth swab samples and complete dietary and quality of life questionnaires. The results of those with liver disease and liver cancer will be compared to the results of their family members without these conditions.

It is hoped this study will show the change in diet drives a more diverse gut microbial community and this has a positive effect on the immune and anti-cancer profile of participants.
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 98394 0
A/Prof Amany Zekry
Address 98394 0
St George Hospital
Department of Gastroenterology and Hepatology
Level 1, Burt Nielsen Wing, Gray St, Kogarah, NSW 2217
Country 98394 0
Australia
Phone 98394 0
+61 2 9113 2817
Fax 98394 0
Email 98394 0
a.zekry@unsw.edu.au
Contact person for public queries
Name 98395 0
Dr Nadia Amorim
Address 98395 0
Microbiome Research Centre - UNSW Sydney
Level 2, Research & Education Building
4-10 South Street, Kogarah, NSW 2217
Country 98395 0
Australia
Phone 98395 0
+61 2 9113 1387
Fax 98395 0
Email 98395 0
n.amorim@unsw.edu.au
Contact person for scientific queries
Name 98396 0
Dr Nadia Amorim
Address 98396 0
Microbiome Research Centre - UNSW Sydney
Level 2, Research & Education Building
4-10 South Street, Kogarah, NSW 2217
Country 98396 0
Australia
Phone 98396 0
+61 2 9113 1387
Fax 98396 0
Email 98396 0
n.amorim@unsw.edu.au

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
rRNA sequencing for microbiome study
The library of the 16S rRNA sequencing will be available for download, as per microbiome studies in general.
All samples will be de-identified, and IPD including gender, age, comorbidities and group names, eg. Control, NAFLD or HCC may be shared.
When will data be available (start and end dates)?
Data will be available after the completion of the study and publication of results. No end date is determined.
Available to whom?
Public
Available for what types of analyses?
Bioinformatics
How or where can data be obtained?
Data will be made available by emailing the project coordinator at "n.amorim@unsw.edu.au" and/or via the website link provided in the published articles.
What supporting documents are/will be available?
No other documents available
Summary results
No Results