Fatty Liver in Obesity: Long-lifestyle Follow-up (FLiO)

Overweight Clinical Trial

— FLiO  

Official title:

Non-alcoholic Fatty Liver Disease (NAFLD) in Overweight and Obese People Under Nutritional and Lifestyle Follow-up: a Randomized Controlled Trial

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03183193
• Other study ID #: FLiO
• Status: Recruiting
• Phase: N/A
• First received: March 31, 2017
• Last updated: June 7, 2017
• Start date: June 2016
• Est. completion date: December 2019

Study information

• Verified date: June 2017
• Source: Clinica Universidad de Navarra, Universidad de Navarra
• Contact: M. Angeles Zulet, PhD
• Phone: +34948425600
• Email: mazulet[@]unav.es
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Non-alcoholic fatty liver disease (NAFLD) is a condition of excessive hepatic lipid accumulation in subjects that consume less than 20g ethanol per day, without other known causes as drugs consumption or toxins exposure. In Western countries, the rate of this disease lies about 30% in the general adult population. The process of developing NAFLD can start from simple steatosis to non-alcoholic steatohepatitis (NASH), which eventually can lead to cirrhosis and hepatocellular carcinoma in the absence of alcohol abuse. Liver biopsy is considered the "gold standard" of steatosis, fibrosis and cirrhosis. However, it is rarely performed because it is an invasive procedure and investigators are focusing in the application of non-invasive liver damage scores for diagnosis.

The pathogenesis of NAFLD is multifactorial and triggered by environmental factors such as unbalanced diets and overnutrition as well as by lack of physical activity in the context of a genetic predisposition. Nowadays, the treatment of NAFLD is based on diet and lifestyle modifications. Weight loss, exercise and healthy eating habits are the main tools to fight NAFLD. Nevertheless, there is no a well characterized dietary pattern and further studies are necessary.

With this background, the general aim of this project is to increase the knowledge on the influence of nutritional/lifestyle interventions in obese patients with NAFLD, as well as contribute to identify non-invasive biomarkers/scores to early diagnosis of this pathology in future obese people.

Description:

This project is framed within the promotion of health and lifestyles and, specifically, in liver disorder linked to obesity (FLiO: Fatty Liver in Obesity).

The investigation addresses a randomized, parallel, long-term personalized nutritional intervention with two strategies: 1) Control diet based on American Heart Association (AHA); 2) Fatty Liver in Obesity (FLiO) diet based on previous results (RESMENA project).The diet is based on macronutrient distribution, quality and quantity, and is characterized by a low glycemic load, high adherence to the Mediterranean diet and a high antioxidant capacity, with the inclusion of anti-inflammatory foods. It also takes into account the distribution of food throughout the day, number of meals, portion sizes, timing of meal, individual needs, dietary behavior (behavioral therapy: eat slowly, teach what to buy, what to eat, when to eat). The participants are instructed to follow this strategy. This strategy (RESMENA) was even more effective than AHA after 6 months follow-up, in terms of significant reduction of abdominal fat and blood glucose level. In addition, this diet had beneficial effects for participants who were obese and had values of altered glucose, reducing significantly in RESMENA participants LDL-oxidized marker. These results are very important to apply in the present investigation since that patients with NAFLD are commonly insulin resistant.

Both strategies were designed within a hypocaloric dietary pattern (-30%) in order to achieve the American Association for the Study of Liver Diseases (AASLD) recommendations for the management of non-alcoholic liver disease (loss of at least 3-5% of body weight appears necessary to improve steatosis, but a greater weight loss, up to 10%, may be needed to improve necroinflammation). At this time the participants are individually supervised and encouraged to follow with the dietary planning instructions assigned. Furthermore, at baseline, 6, 12 and 24 months anticipated variables are obtained. Both dietary groups receive routine control (weight, body composition, strategy adherence) and dietary advice daily by phone (if they need help) and face to face at the time of routine control.

In order to get a integral lifestyle intervention, all participants will be encouraged to follow a healthy lifestyle. Thus, physical activity will be recorded in each dietary group.

The specific tasks:

1. To recruit and select patients with the adequate characteristics to validate the conclusions reached.

2. To develop and adequately transmit to each patient a personalized strategy according to the group randomly assigned ( AASLD vs FLiO strategy).

3. To check the degree of adherence to the strategy set by regular monitoring:

semiquantitative questionnaires of food consumption frequency, pedometers, accelerometers, weight control, satiety.

4. To assess the effect of each strategy on body composition (weight, waist circumference, body fat, muscle mass, bone mineral density), physical status, general biochemistry (lipid profile, glycaemic profile, albumin, blood count, transaminases), specific biomarkers/metabolites in blood or urine (inflammation, oxidative stress, liver damage, appetite, psychological status), quality of life and related factors (anxiety, depression and sleep).

5. To check the evolution of the liver damage, using non-invasive techniques (ultrasound, elastography and magnetic resonance imaging (MRI), metabolomics analysis) and calculating different validated liver scores from the data obtained with each strategy.

6. To compare the effectiveness of strategies, considering not only the ability to decrease body fat, but also other risk factors present in the NAFLD patient such as insulin resistance and cardiovascular risk, which will result in improvement of liver damage.

7. To analyze SNPs (DNA from oral epithelial cells) and the association with NAFLD (diagnosis and response to the strategies).

8. To study gene expression (mRNAs) and microRNAs in white blood cells for identifying biomarkers of diagnosis and response to dietary strategy.

9. To analyze gene DNA methylation patterns in white blood cells for identifying biomarkers of diagnosis and response to dietary strategy.

10. To describe the intestinal microbiota composition by 16s sequencing at baseline and after nutritional intervention for diagnosis and response.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 120
• Est. completion date: December 2019
• Est. primary completion date: December 2017
• Accepts healthy volunteers: No
• Gender: All
• Age group: 30 Years to 80 Years

Eligibility

Inclusion Criteria:

• Overweight or obese

• Diagnosis of NAFLD

• Age: 30-80 years

• Female / Male

Exclusion Criteria:

• Known liver disease (other than NAFLD)

• Abuse of alcohol (>21 and >14 units of alcohol a week for men and women, respectively, eg 1 unit = 125 mL of wine);

• Drug treatments: immunosuppressants, cytotoxic agents, systemic corticosteroids, agents potentially causing fatty liver disease or abnormal liver tests or weight modifiers

• Active cancer or a history of malignancy in the last 5 years

• Problems of massive edemas

• Obesity known endocrine origin (except treated hypothyroidism)

• Surgical procedure for weight loss

• = 3kg weight loss in the last 3 months

• Severe psychiatric disorders

• Lack of autonomy or inability to follow the diet (including food allergies or intolerances) or/and lifestyle recommendations as well as to follow scheduled visits.

• Consumption of any type of food supplements (antioxidants, prebiotics, probiotics, etc.)

Related Conditions & MeSH terms

• Fatty Liver
• Liver Diseases
• Non-Alcoholic Fatty Liver Disease
• Obese
• Overweight

Intervention

Other:
• Control diet
The participants follow a conventional and balanced distribution of macronutrients (30% fat, 15% protein, 55% carbohydrates), adequate fiber (25-30 g/day) and dietary cholesterol (<250 mg/day) intake according to AHA guidelines. This strategy was included within a personalized energy-restricted diet (-30% individual needs) under healthy lifestyle advice in order to achieve the objectives of AASLD (loss of at least 3-5% of the initial body weight and up to 10% needed to improve necroinflammation).
• FLiO diet
The participants follow a strategy based on a distribution of macronutrients 30-35% lipid (extra virgin olive oil and fatty acids ?3 in detriment of saturated, trans and cholesterol)/ protein 25% (vegetable against animal)/carbohydrates 40-45% (low glycaemic index, fiber 30-35 g/day); high adherence to the Mediterranean diet and natural antioxidants; meal frequency of 7 meals/day; size/composition of the ration suitable for each moment; including traditional foods with no additional economic cost that will allow diet adherence without abandonment; avoid inappropriate mealtimes and the eating manners as the eating rate. The participants are instructed to follow this strategy within a personalized energy-restricted diet (-30%) and under healthy lifestyle advice to achieve AASLD objectives.

Locations

Country	Name	City	State
Spain	Centre for Nutrition Research, University of Navarra	Pamplona	Navarra

Sponsors (2)

Lead Sponsor	Collaborator
Clinica Universidad de Navarra, Universidad de Navarra	Complejo Hospitalario de Navarra

Country where clinical trial is conducted

Spain, 

References & Publications (6)

Abd El-Kader SM, El-Den Ashmawy EM. Non-alcoholic fatty liver disease: The diagnosis and management. World J Hepatol. 2015 Apr 28;7(6):846-58. doi: 10.4254/wjh.v7.i6.846. Review. — View Citation

Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ; American Gastroenterological Association; American Association for the Study of Liver Diseases; American College of Gastroenterologyh. The diagnosis and management of n — View Citation

de la Iglesia R, Lopez-Legarrea P, Abete I, Bondia-Pons I, Navas-Carretero S, Forga L, Martinez JA, Zulet MA. A new dietary strategy for long-term treatment of the metabolic syndrome is compared with the American Heart Association (AHA) guidelines: the MEtabolic Syndrome REduction in NAvarra (RESMENA) project. Br J Nutr. 2014 Feb;111(4):643-52. doi: 10.1017/S0007114513002778. Epub 2013 Aug 23. — View Citation

de la Iglesia R, Lopez-Legarrea P, Celada P, Sánchez-Muniz FJ, Martinez JA, Zulet MA. Beneficial effects of the RESMENA dietary pattern on oxidative stress in patients suffering from metabolic syndrome with hyperglycemia are associated to dietary TAC and fruit consumption. Int J Mol Sci. 2013 Mar 27;14(4):6903-19. doi: 10.3390/ijms14046903. — View Citation

Lopez-Legarrea P, de la Iglesia R, Abete I, Bondia-Pons I, Navas-Carretero S, Forga L, Martinez JA, Zulet MA. Short-term role of the dietary total antioxidant capacity in two hypocaloric regimes on obese with metabolic syndrome symptoms: the RESMENA randomized controlled trial. Nutr Metab (Lond). 2013 Feb 13;10(1):22. doi: 10.1186/1743-7075-10-22. — View Citation

Yasutake K, Kohjima M, Kotoh K, Nakashima M, Nakamuta M, Enjoji M. Dietary habits and behaviors associated with nonalcoholic fatty liver disease. World J Gastroenterol. 2014 Feb 21;20(7):1756-67. doi: 10.3748/wjg.v20.i7.1756. Review. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change from Baseline Weight at 6 months	Weight will be measured by a digital scale	Baseline and 6 months
Primary	Change from 6 month Weight at 12 months	Weight will be measured by a digital scale	6 months and 12 months
Primary	Change from Baseline Weight at 12 months	Weight will be measured by a digital scale	Baseline and 12 months
Secondary	Change from Baseline Body fat at 6 months	Fat mass will be measured by Dual X-ray absorptiometry	Baseline and 6 months
Secondary	Change from 6 month Body fat at 12 months	Fat mass will be measured by Dual X-ray absorptiometry	6 months and 12 months
Secondary	Change from Baseline Body fat at 12 months	Fat mass will be measured by Dual X-ray absorptiometry	Baseline and 12 months
Secondary	Change from Baseline Waist circumference at 6 months	Waist circumference will be measured with a tape measure	Baseline and 6 months
Secondary	Change from 6 month Waist circumference at 12 months	Waist circumference will be measured with a tape measure	6 months and 12 months
Secondary	Change from Baseline Waist circumference at 12 months	Waist circumference will be measured with a tape measure	Baseline and 12 months
Secondary	Change from Baseline handgrip strength at 6 months	Handgrip strength will be measured with a dynamometer	Baseline and 6 months
Secondary	Change from 6 month handgrip strength at 12 months	Handgrip strength will be measured with a dynamometer	6 months and 12 months
Secondary	Change from Baseline handgrip strength at 12 months	Handgrip strength will be measured with a dynamometer	Baseline and 12 months
Secondary	Change from Baseline Systolic blood pressure at 6 months	Systolic blood pressure will be measured with a sphygmomanometer	Baseline and 6 months
Secondary	Change from 6 month Systolic blood pressure at 12 months	Systolic blood pressure will be measured with a sphygmomanometer	6 months and 12 months
Secondary	Change from Baseline Systolic blood pressure at 12 months	Systolic blood pressure will be measured with a sphygmomanometer	Baseline and 12 months
Secondary	Change from Baseline Diastolic blood pressure at 6 months	Diastolic blood pressure will be measured with a sphygmomanometer	Baseline and 6 months
Secondary	Change from 6 month Diastolic blood pressure at 12 months	Diastolic blood pressure will be measured with a sphygmomanometer	6 months and 12 months
Secondary	Change from Baseline Diastolic blood pressure at 12 months	Diastolic blood pressure will be measured with a sphygmomanometer	Baseline and 12 months
Secondary	Change from Baseline lipid metabolism at 6 months	Serum free fatty acids, triglycerides, total cholesterol, LDL cholesterol and HDL cholesterol concentrations will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month lipid metabolism at 12 months	Serum free fatty acids, triglycerides, total cholesterol, LDL cholesterol and HDL cholesterol concentrations will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline lipid metabolism at 12 months	Serum free fatty acids, triglycerides, total cholesterol, LDL cholesterol and HDL cholesterol concentrations will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline uric acid concentration at 6 months	Serum uric acid will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month uric acid concentration at 12 months	Serum uric acid will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline uric acid concentration at 12 months	Serum uric acid will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline homocysteine concentration at 6 months	Serum homocysteine will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month homocysteine concentration at 12 months	Serum homocysteine will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline homocysteine concentration at 12 months	Serum homocysteine will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline glucose metabolism at 6 months	Serum glucose levels will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month glucose metabolism at 12 months	Serum glucose levels will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline glucose metabolism at 12 months	Serum glucose levels will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline insulin concentration at 6 months	Serum insulin levels will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month insulin concentration at 12 months	Serum insulin levels will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline insulin concentration at 12 months	Serum insulin levels will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline Hemoglobin A1c concentration at 6 months	Serum Hemoglobin A1c will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month Hemoglobin A1c concentration at 12 months	Serum Hemoglobin A1c will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline Hemoglobin A1c concentration at 12 months	Serum Hemoglobin A1c will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline liver function at 6 months	Serum aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, total bilirubin, direct bilirubin, alkaline phosphatase, creatinine, total protein, albumin, prothrombin will be measured in a fasting state	Baseline and 12 months
Secondary	Change from 6 month liver function at 12 months	Serum aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, total bilirubin, direct bilirubin, alkaline phosphatase, creatinine, total protein, albumin, prothrombin will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline liver function at 12 months	Serum aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, total bilirubin, direct bilirubin, alkaline phosphatase, creatinine, total protein, albumin, prothrombin will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline fibroblast growth factor 21 (FGF21) concentration at 6 months	Plasma FGF21 is a specific biomarker of NAFLD and will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month fibroblast growth factor 21 (FGF21) concentration at 12 months	Plasma FGF21 is a specific biomarker of NAFLD and will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline fibroblast growth factor 21 (FGF21) concentration at 12 months	Plasma FGF21 is a specific biomarker of NAFLD and will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline cytokeratin-18 (CK18) concentration at 6 months	Plasma CK18 is a specific biomarker of NAFLD and will be measured in a fasting state	Baseline and 6 months
Secondary	Change from 6 month cytokeratin-18 (CK18) concentration at 12 months	Plasma CK18 is a specific biomarker of NAFLD and will be measured in a fasting state	6 months and 12 months
Secondary	Change from Baseline cytokeratin-18 (CK18) concentration at 12 months	Plasma CK18 is a specific biomarker of NAFLD and will be measured in a fasting state	Baseline and 12 months
Secondary	Change from Baseline C-reactive protein (CRP) concentration at 6 months	Plasma CRP will be assessed to determine inflammatory status	Baseline and 6 months
Secondary	Change from 6 month C-reactive protein (CRP) concentration at 12 months	Plasma CRP will be assessed to determine inflammatory status	6 months and 12 months
Secondary	Change from Baseline C-reactive protein (CRP) concentration at 12 months	Plasma CRP will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline interleukin 6 (IL-6) concentration at 6 months	Plasma IL-6 will be assessed to determine inflammatory status	Baseline and 6 months
Secondary	Change from 6 month interleukin 6 (IL-6) concentration at 12 months	Plasma IL-6 will be assessed to determine inflammatory status	6 months and 12 months
Secondary	Change from Baseline interleukin 6 (IL-6) concentration at 12 months	Plasma IL-6 will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline tumor necrosis factor-a (TNFa) concentration at 6 months	Plasma TNF-alpha will be assessed to determine inflammatory status	Baseline and 6 months
Secondary	Change from 6 month tumor necrosis factor-a (TNFa) concentration at 12 months	Plasma TNF-alpha will be assessed to determine inflammatory status	6 months and 12 months
Secondary	Change from Baseline tumor necrosis factor-a (TNFa) concentration at 12 months	Plasma TNF-alpha will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline leptin concentration at 6 months	Plasma leptin will be assessed to determine inflammatory status	Baseline and 6 months
Secondary	Change from 6 month leptin concentration at 12 months	Plasma leptin will be assessed to determine inflammatory status	6 months and 12 months
Secondary	Change from Baseline leptin concentration at 12 months	Plasma leptin will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline adiponectin concentration at 6 months	Plasma leptin will be assessed to determine inflammatory status	Baseline and 6 months
Secondary	Change from 6 month adiponectin concentration at 12 months	Plasma adiponectin will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline adiponectin concentration at 12 months	Plasma adiponectin will be assessed to determine inflammatory status	Baseline and 12 months
Secondary	Change from Baseline LDL-oxidized concentration at 6 months	LDL-ox will be assessed to determine oxidative status	Baseline and 6 months
Secondary	Change from 6 month LDL-oxidized concentration at 12 months	LDL-ox will be assessed to determine oxidative status	6 months and 12 months
Secondary	Change from Baseline LDL-oxidized concentration at 12 months	LDL-ox will be assessed to determine oxidative status	Baseline and 12 months
Secondary	Change from Baseline Malondialdehyde concentration at 6 months	Plasma malondialdehyde will be assessed to determine oxidative status	Baseline and 6 months
Secondary	Change from 6 month Malondialdehyde concentration at 12 months	Plasma malondialdehyde will be assessed to determine oxidative status	6 months and 12 months
Secondary	Change from Baseline Malondialdehyde concentration at 12 months	Plasma malondialdehyde will be assessed to determine oxidative status	Baseline and 12 months
Secondary	Change from Baseline plasma antioxidant capacity at 6 months	Plasma antioxidant capacity will be assessed by measuring the ferric reducing ability of plasma (FRAP)	Baseline and 6 months
Secondary	Change from 6 month plasma antioxidant capacity at 12 months	Plasma antioxidant capacity will be assessed by measuring the ferric reducing ability of plasma (FRAP)	6 months and 12 months
Secondary	Change from Baseline plasma antioxidant capacity at 12 months	Plasma antioxidant capacity will be assessed by measuring the ferric reducing ability of plasma (FRAP)	Baseline and 12 months
Secondary	Change from Baseline Hepatic echography at 6 months	Echography will be carried out to analyze liver steatosis	Baseline and 6 months
Secondary	Change from 6 month Hepatic echography at 12 months	Echography will be carried out to analyze liver steatosis	6 months and 12 months
Secondary	Change from Baseline Hepatic echography at 12 months	Echography will be carried out to analyze liver steatosis	Baseline and 12 months
Secondary	Change from Baseline Hepatic elastography at 6 months	Elastography will be carried out to analyze liver fibrosis	Baseline and 6 months
Secondary	Change from 6 month Hepatic elastography at 12 months	Elastography will be carried out to analyze liver fibrosis	6 months and 12 months
Secondary	Change from Baseline Hepatic elastography at 12 months	Elastography will be carried out to analyze liver fibrosis	Baseline and 12 months
Secondary	Change from Baseline Hepatic Magnetic Resonance Imaging at 6 months	Magnetic Resonance Imaging will be carried out to analyze liver status	Baseline and 6 months
Secondary	Change from 6 month Hepatic Magnetic Resonance Imaging at 12 months	Magnetic Resonance Imaging will be carried out to analyze liver status	6 months and 12 months
Secondary	Change from Baseline Hepatic Magnetic Resonance Imaging at 12 months	Magnetic Resonance Imaging will be carried out to analyze liver status	Baseline and 12 months
Secondary	Change from Baseline White blood cell count at 6 months	White blood cell count includes: Leucocytes, Neutrophils, Lymphocytes, Monocytes, Eosinophil, Basophils.	Baseline and 6 months
Secondary	Change from 6 month White blood cell count at 12 months	White blood cell count includes: Leucocytes, Neutrophils, Lymphocytes, Monocytes, Eosinophil, Basophils.	6 months and 12 months
Secondary	Change from Baseline White blood cell count at 12 months	White blood cell count includes: Leucocytes, Neutrophils, Lymphocytes, Monocytes, Eosinophil, Basophils.	Baseline and 12 months
Secondary	Change from Baseline blood rheological properties at 6 months	Red blood cell count, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cell distribution width, platelet count, platelet distribution width, mean platelet volume, plateletcrit	Baseline and 6 months
Secondary	Change from 6 month blood rheological properties at 12 months	Red blood cell count, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cell distribution width, platelet count, platelet distribution width, mean platelet volume, plateletcrit	6 months and 12 months
Secondary	Change from Baseline blood rheological properties at 12 months	Red blood cell count, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cell distribution width, platelet count, platelet distribution width, mean platelet volume, plateletcrit	Baseline and 12 months
Secondary	Change from Baseline Physical activity level at 6 months	Physical activity will be assessed by accelerometers	Baseline and 6 months
Secondary	Change from 6 months Physical activity level at 12 months	Physical activity will be assessed accelerometers	6 months and 12 months
Secondary	Change from Baseline Physical activity level at 12 months	Physical activity will be assessed by accelerometers	Baseline and 12 months
Secondary	Change from Baseline Minnesota Physical Activity test at 6 months	Physical activity assessed by Minnesota Physical Activity test	Baseline and 6 months
Secondary	Change from 6 month Minnesota Physical Activity test at 12 months	Physical activity assessed by Minnesota Physical Activity test	6 months and 12 months
Secondary	Change from Baseline Minnesota Physical Activity test at 12 months	Physical activity assessed by Minnesota Physical Activity test	Baseline and 12 months
Secondary	Change from Baseline number of steps at 6 months	Physical activity assessed by Pedometers	Baseline and 6 months
Secondary	Change from 6 month number of steps at 12 months	Physical activity assessed by Pedometers	6 months and 12 months
Secondary	Change from Baseline number of steps at 12 months	Physical activity assessed by Pedometers	Baseline and 12 months
Secondary	Change from Baseline chair test at 6 months	Physical activity assessed by the chair test	Baseline and 6 months
Secondary	Change from 6 month chair test at 12 months	Physical activity assessed by the chair test	6 months and 12 months
Secondary	Change from Baseline chair test at 12 months	Physical activity assessed by the chair test	Baseline and 12 months
Secondary	Change from Baseline sleep quality at 6 months	Sleep information will be assessed by the Pittsburgh Sleep Quality Index	Baseline and 12 months
Secondary	Change from 6 month sleep quality at 12 months	Sleep information will be assessed by the Pittsburgh Sleep Quality Index	6 months and 12 months
Secondary	Change from Baseline sleep quality at 12 months	Sleep information will be assessed by the Pittsburgh Sleep Quality Index	Baseline and 12 months
Secondary	Change from Baseline Depressive symptoms at 6 months	Depressive symptoms will be assessed by the Beck Depression Inventory (BDI)	Baseline and 6 months
Secondary	Change from 6 month Depressive symptoms at 12 months	Depressive symptoms will be assessed by the Beck Depression Inventory (BDI)	6 months and 12 months
Secondary	Change from Baseline Depressive symptoms at 12 months	Depressive symptoms will be assessed by the Beck Depression Inventory (BDI)	Baseline and 12 months
Secondary	Change from Baseline Anxiety symptoms at 6 months	Anxiety symptoms will be assessed by State Anxiety test (STAI)	Baseline and 6 months
Secondary	Change from 6 month Anxiety symptoms at 12 months	Anxiety symptoms will be assessed by State Anxiety test (STAI)	6 months and 12 months
Secondary	Change from Baseline Anxiety symptoms at 12 months	Anxiety symptoms will be assessed by State Anxiety test (STAI)	Baseline and 12 months
Secondary	Single Nucleotide polymorphisms (SNPs)	Single nucleotide polymorphisms will be determined by Genomic DNA from oral epithelial cells	Baseline
Secondary	Change from Baseline DNA methylation at 6 months	Epigenetics will be assessed by changes in DNA methylation of genes related with NAFLD development	Baseline and 6 months
Secondary	Change from 6 month DNA methylation at 12 months	Epigenetics will be assessed by changes in DNA methylation of genes related with NAFLD development	6 months and 12 months
Secondary	Change from Baseline DNA methylation at 12 months	Epigenetics will be assessed by changes in DNA methylation of genes related with NAFLD development	Baseline and 12 months
Secondary	Change from Baseline microRNAs at 6 months	Transcriptomic will be assessed by changes in miRNAs	Baseline and 6 months
Secondary	Change from 6 month microRNAs at 12 months	Transcriptomic will be assessed by changes in miRNAs	6 months and 12 months
Secondary	Change from Baseline microRNAs at 12 months	Transcriptomic will be assessed by changes in miRNAs	Baseline and 12 months
Secondary	Change from Baseline Gut microbiota composition at 6 months	Gut microbiota composition will be analyzed	Baseline and 6 months
Secondary	Change from 6 month Gut microbiota composition at 12 month	Gut microbiota composition will be analyzed	6 months and 12 months
Secondary	Change from Baseline Gut microbiota composition at 12 month	Gut microbiota composition will be analyzed	Baseline and 12 months
Secondary	Change from Baseline metabolites composition of urine at 6 months	Metabolites composition of urine will be analyzed	Baseline and 6 months
Secondary	Change from 6 month metabolites composition of urine at 12 months	Metabolites composition of urine will be analyzed	6 months and 12 months
Secondary	Change from Baseline metabolites composition of urine at 12 months	Metabolites composition of urine will be analyzed	Baseline and 12 months
Secondary	Change from Baseline metabolites composition of serum at 6 months	Metabolites composition of serum will be analyzed	Baseline and 6 months
Secondary	Change from 6 month metabolites composition of serum at 12 months	Metabolites composition of serum will be analyzed	6 months and 12 months
Secondary	Change from Baseline metabolites composition of serum at 12 months	Metabolites composition of serum will be analyzed	Baseline and 12 months
Secondary	Change from Baseline dietary intake at 6 months	Dietary intake will be assessed by means of food frequency questionnaire	Baseline and 6 months
Secondary	Change from 6 month dietary intake at 12 months	Dietary intake will be assessed by means of food frequency questionnaire	6 months and 12 months
Secondary	Change from Baseline dietary intake at 12 months	Dietary intake will be assessed by means of food frequency questionnaire	Baseline and 12 months
Secondary	Assessment of dietary adherence at Baseline	Dietary adherence will be assessed by means of 3 day weighed food records	Baseline
Secondary	Assessment of dietary adherence at 6 months	Dietary adherence will be assessed by means of 3 day weighed food records	6 months
Secondary	Assessment of dietary adherence at 12 months	Dietary adherence will be assessed by means of 3 day weighed food records	12 months
Secondary	Change from Baseline satiety index at 6 months	Satiety index/appetite will be assessed by using the 100 mm Visual Analogue Scale	Baseline and 6 months
Secondary	Change from 6 month satiety index at 12 months	Satiety index/appetite will be assessed by using the 100 mm Visual Analogue Scale	6 months and 12 months
Secondary	Change from Baseline satiety index at 12 months	Satiety index/appetite will be assessed by using the 100 mm Visual Analogue Scale	Baseline and 12 months
Secondary	Change from Baseline life quality index at 6 months	Life quality index will be assessed by means of the Short Form 36 (SF-36) questionnaire	Baseline and 6 months
Secondary	Change from 6 month life quality index at 12 months	Life quality index will be assessed by means of the Short Form 36 (SF-36) questionnaire	6 months and 12 months
Secondary	Change from Baseline life quality index at 12 months	Life quality index will be assessed by means of the Short Form 36 (SF-36) questionnaire	Baseline and 12 months
Secondary	Change from Baseline Ghrelin concentration at 6 months	Serum Active Ghrelin will be determined to assess satiety	Baseline and 6 months
Secondary	Change from 6 month Ghrelin concentration at 12 months	Serum Active Ghrelin will be determined to assess satiety	6 months and 12 months
Secondary	Change from Baseline Ghrelin concentration at 12 months	Serum Active Ghrelin will be determined to assess satiety	Baseline and 12 months
Secondary	Change from Baseline glucagon-like peptide-1 (GLP-1) concentration at 6 months	Serum active glucagon-like peptide-1 will be determined to assess satiety	Baseline and 6 months
Secondary	Change from 6 month glucagon-like peptide-1 (GLP-1) concentration at 12 months	Serum active glucagon-like peptide-1 will be determined to assess satiety	6 months and 12 months
Secondary	Change from Baseline glucagon-like peptide-1 (GLP-1) concentration at 12 months	Serum active glucagon-like peptide-1 will be determined to assess satiety	Baseline and 12 months
Secondary	Change from Baseline Dopamine concentration at 6 months	Peripheral Dopamine concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 6 months
Secondary	Change from 6 month Dopamine concentration at 12 months	Peripheral Dopamine concentration will be analysed using high-performance liquid chromatography (HPLC)	6 months and 12 months
Secondary	Change from Baseline Dopamine concentration at 12 months	Peripheral Dopamine concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 12 months
Secondary	Change from Baseline Dopac concentration at 6 months	Peripheral Dopac concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 6 months
Secondary	Change from 6 month Dopac concentration at 12 months	Peripheral Dopac concentration will be analysed using high-performance liquid chromatography (HPLC)	6 months and 12 months
Secondary	Change from Baseline Dopac concentration at 12 months	Peripheral Dopac concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 12 months
Secondary	Change from Baseline Serotonin (5-HT) concentration at 6 months	Peripheral Serotonin concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 6 months
Secondary	Change from 6 month Serotonin (5-HT) concentration at 12 months	Peripheral Serotonin concentration will be analysed using high-performance liquid chromatography (HPLC)	6 months and 12 months
Secondary	Change from Baseline Serotonin (5-HT) concentration at 12 months	Peripheral Serotonin concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 12 months
Secondary	Change from Baseline Noradrenaline concentration at 6 months	Peripheral Noradrenaline concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 6 months
Secondary	Change from 6 month Noradrenaline concentration at 12 months	Peripheral Noradrenaline concentration will be analysed using high-performance liquid chromatography (HPLC)	6 months and 12 months
Secondary	Change from Baseline Noradrenaline concentration at 12 months	Peripheral Noradrenaline concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 12 months
Secondary	Change from Baseline 5-hydroxyindoleacetic acetic (5-HIAAC) concentration at 6 months	Peripheral 5-hydroxyindoleacetic acetic concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 6 months
Secondary	Change from 6 month 5-hydroxyindoleacetic acetic (5-HIAAC) concentration at 12 months	Peripheral 5-hydroxyindoleacetic acetic concentration will be analysed using high-performance liquid chromatography (HPLC)	6 months and 12 months
Secondary	Change from Baseline 5-hydroxyindoleacetic acetic (5-HIAAC) concentration at 12 months	Peripheral 5-hydroxyindoleacetic acetic concentration will be analysed using high-performance liquid chromatography (HPLC)	Baseline and 12 months