The Impact of Fitness and Mineralocorticoid Receptor Blockade on Vascular Dysfunction in Adults With Type 1 Diabetes

Type 1 Diabetes Clinical Trial

— EJB048  

Official title:

The Impact of Fitness and Mineralocorticoid Receptor Blockade on Vascular Dysfunction in Adults With Type 1 Diabetes

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03174288
• Other study ID #: 18237
• Secondary ID: 5R01DK101944-03
• Status: Completed
• Phase: N/A
• Start date: August 2015
• Est. completion date: May 22, 2019

Study information

• Verified date: December 2019
• Source: University of Virginia
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

In this protocol, 60 subjects with DM1 will be studied at baseline, after 12 weeks of MCR blockade or 12 weeks of exercise, and again after an additional 12 weeks of MCR blockade, exercise or the combination of both interventions. The investigators will assess function in conduit (pulse wave velocity-PWV, flow-mediated dilation-FMD and augmentation index-AI), resistance (post-ischemic flow velocity-PIFV) and heart and skeletal muscle microvascular (contrast enhanced ultrasound-CEU) vessels before and after 2 hrs of a euglycemic insulin clamp.

We hypothesize that compared to healthy controls, both baseline and insulin-responsive vascular function are impaired throughout the arterial vasculature by DM1 and that exercise training and/or mineralocorticoid receptor (MCR) blockade will improve both baseline and insulin-responsive pan-arterial function.

Description:

Using non-invasive methods, several small studies have demonstrated conduit artery stiffness and other small studies report impaired brachial artery nitric oxide (NO) release in subjects with type diabetes (DM1). Vascular insulin action (characterized by insulin-induced NO-mediated vasodilation of conduit, resistance or microvascular vessels) has not been studied systematically in DM1. The investigators hypothesize that compared to healthy controls, both baseline and insulin-responsive vascular function are impaired throughout the arterial vasculature by DM1 and that exercise training and/or mineralocorticoid receptor (MCR) blockade will improve both baseline and insulin-responsive pan-arterial function.

In this protocol, 60 subjects with DM1 will be studied at baseline, after 12 weeks of MCR blockade or 12 weeks of exercise, and again after an additional 12 weeks of MCR blockade, exercise or the combination of both interventions. Investigators will assess function in conduit (pulse wave velocity-PWV, flow-mediated dilation-FMD and augmentation index-AI), resistance (post-ischemic flow velocity-PIFV) and heart and skeletal muscle microvascular (contrast enhanced ultrasound-CEU) vessels before and after 2 hrs of a euglycemic insulin clamp.

This work will: a) identify whether vascular stiffness and indices of NO action are impaired throughout the arterial tree in DM1; b) identify the impact of fitness, MCR blockade or the combination to improve vascular function; and c) introduce a rational paradigm for early, proof-of-concept testing of interventions that may improve vascular health in DM1. While multiple endpoints are measured in the proposed studies, the investigators designate one primary conduit vessel endpoint (augmentation index) and one primary microvascular endpoint (microvascular blood volume by CEU); the studies are powered on these measures. The investigators believe that their laboratories are in a unique position with respect to their demonstrated scientific expertise to deliver this fundamental information.

The study proposed here will be the first to assess whether: 1) basal pan-arterial function including myocardial microvascular function is adversely affected by DM1 ; 2) vascular insulin responsiveness in DM1 is impaired as is seen in DM2 3) exercise training or MCR blockade alone or in combination favorably impacts vascular stiffness or NO-induced relaxation in DM1 in the basal state or in response to insulin. This non-invasive vascular profiling provides a functional "biomarker" of pan-arterial health. As such it could be useful for assessing the impact of specific short-term interventions on critical vascular functions in small scale studies (e.g. MCR blockade, statins, GLP-1R agonists) and thereby provide a rationale for selection of candidate therapies for subsequent larger clinical outcome trials. Additionally, non-invasive assessment of pan-arterial function could provide a platform to identify patients for early or more intensive treatment interventions as part of their care plan.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 32
• Est. completion date: May 22, 2019
• Est. primary completion date: May 22, 2019
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 18 Years to 50 Years

Eligibility

Inclusion Criteria:

• Age 18-50 years

• BMI =30

• No clinically significant lab values other than those consistent with DM1

• Subjects will have been on insulin for at least 5 years and HbA1c <9

Exclusion Criteria:

• Smoking presently or in the past 6 months

• Medications that affect the vasculature (except ACE or ARB , although they will need to be off these drugs for 2 weeks prior to study).

• Elevated LDL cholesterol > 160

• BP <100/60 or >160/90

• Pulse oximetry <90%

• Pregnant or breastfeeding

• History of cardiovascular disease, cerebral vascular disease, peripheral vascular disease, liver disease

• Presence of an intracardiac or intrapulmonary shunt (we will screen for this by auscultation during the physical exam).

• Known hypersensitivity to perflutren (contained in Definity)

• Serum Potassium =5.0

• HbA1c = 9

• Retinopathy

• Ketoacidosis within the past year.

Related Conditions & MeSH terms

• Diabetes Mellitus
• Diabetes Mellitus, Type 1
• Type 1 Diabetes

Intervention

Other:
• Exercise
24 weeks of exercise treatment

Drug:
• Spironolactone
24 weeks of spironolactone

Locations

Country	Name	City	State
United States	University of Virginia	Charlottesville	Virginia

Sponsors (2)

Lead Sponsor	Collaborator
University of Virginia	National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Country where clinical trial is conducted

United States, 

References & Publications (58)

Anderson TJ, Charbonneau F, Title LM, Buithieu J, Rose MS, Conradson H, Hildebrand K, Fung M, Verma S, Lonn EM. Microvascular function predicts cardiovascular events in primary prevention: long-term results from the Firefighters and Their Endothelium (FATE) study. Circulation. 2011 Jan 18;123(2):163-9. doi: 10.1161/CIRCULATIONAHA.110.953653. Epub 2011 Jan 3. — View Citation

Asmar R, Benetos A, Topouchian J, Laurent P, Pannier B, Brisac AM, Target R, Levy BI. Assessment of arterial distensibility by automatic pulse wave velocity measurement. Validation and clinical application studies. Hypertension. 1995 Sep;26(3):485-90. — View Citation

Baron AD, Steinberg HO, Chaker H, Leaming R, Johnson A, Brechtel G. Insulin-mediated skeletal muscle vasodilation contributes to both insulin sensitivity and responsiveness in lean humans. J Clin Invest. 1995 Aug;96(2):786-92. — View Citation

Baron AD. Hemodynamic actions of insulin. Am J Physiol. 1994 Aug;267(2 Pt 1):E187-202. Review. — View Citation

Barrett EJ, Eggleston EM, Inyard AC, Wang H, Li G, Chai W, Liu Z. The vascular actions of insulin control its delivery to muscle and regulate the rate-limiting step in skeletal muscle insulin action. Diabetologia. 2009 May;52(5):752-64. doi: 10.1007/s00125-009-1313-z. Epub 2009 Mar 13. Review. — View Citation

Barrett EJ, Wang H, Upchurch CT, Liu Z. Insulin regulates its own delivery to skeletal muscle by feed-forward actions on the vasculature. Am J Physiol Endocrinol Metab. 2011 Aug;301(2):E252-63. doi: 10.1152/ajpendo.00186.2011. Epub 2011 May 24. Review. — View Citation

Behrendt D, Ganz P. Endothelial function. From vascular biology to clinical applications. Am J Cardiol. 2002 Nov 21;90(10C):40L-48L. Review. — View Citation

Boutouyrie P, Tropeano AI, Asmar R, Gautier I, Benetos A, Lacolley P, Laurent S. Aortic stiffness is an independent predictor of primary coronary events in hypertensive patients: a longitudinal study. Hypertension. 2002 Jan;39(1):10-5. — View Citation

Chai W, Liu J, Jahn LA, Fowler DE, Barrett EJ, Liu Z. Salsalate attenuates free fatty acid-induced microvascular and metabolic insulin resistance in humans. Diabetes Care. 2011 Jul;34(7):1634-8. doi: 10.2337/dc10-2345. Epub 2011 May 26. — View Citation

Chan A, Barrett EJ, Anderson SM, Kovatchev BP, Breton MD. Muscle microvascular recruitment predicts insulin sensitivity in middle-aged patients with type 1 diabetes mellitus. Diabetologia. 2012 Mar;55(3):729-36. doi: 10.1007/s00125-011-2402-3. Epub 2011 Dec 14. — View Citation

Clark AD, Barrett EJ, Rattigan S, Wallis MG, Clark MG. Insulin stimulates laser Doppler signal by rat muscle in vivo, consistent with nutritive flow recruitment. Clin Sci (Lond). 2001 Mar;100(3):283-90. — View Citation

Clarkson P, Celermajer DS, Donald AE, Sampson M, Sorensen KE, Adams M, Yue DK, Betteridge DJ, Deanfield JE. Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels. J Am Coll Cardiol. 1996 Sep;28(3):573-9. — View Citation

Clausen P, Jacobsen P, Rossing K, Jensen JS, Parving HH, Feldt-Rasmussen B. Plasma concentrations of VCAM-1 and ICAM-1 are elevated in patients with Type 1 diabetes mellitus with microalbuminuria and overt nephropathy. Diabet Med. 2000 Sep;17(9):644-9. — View Citation

Clerk LH, Vincent MA, Barrett EJ, Lankford MF, Lindner JR. Skeletal muscle capillary responses to insulin are abnormal in late-stage diabetes and are restored by angiotensin-converting enzyme inhibition. Am J Physiol Endocrinol Metab. 2007 Dec;293(6):E1804-9. Epub 2007 Oct 2. — View Citation

Clerk LH, Vincent MA, Jahn LA, Liu Z, Lindner JR, Barrett EJ. Obesity blunts insulin-mediated microvascular recruitment in human forearm muscle. Diabetes. 2006 May;55(5):1436-42. — View Citation

Coggins M, Lindner J, Rattigan S, Jahn L, Fasy E, Kaul S, Barrett E. Physiologic hyperinsulinemia enhances human skeletal muscle perfusion by capillary recruitment. Diabetes. 2001 Dec;50(12):2682-90. — View Citation

Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004 Aug 21-27;364(9435):685-96. — View Citation

Corretti MC, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F, Creager MA, Deanfield J, Drexler H, Gerhard-Herman M, Herrington D, Vallance P, Vita J, Vogel R; International Brachial Artery Reactivity Task Force. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the International Brachial Artery Reactivity Task Force. J Am Coll Cardiol. 2002 Jan 16;39(2):257-65. Erratum in: J Am Coll Cardiol 2002 Mar 20;39(6):1082. — View Citation

de Graaf JC, Banga JD, Moncada S, Palmer RM, de Groot PG, Sixma JJ. Nitric oxide functions as an inhibitor of platelet adhesion under flow conditions. Circulation. 1992 Jun;85(6):2284-90. — View Citation

Eggleston EM, Jahn LA, Barrett EJ. Hyperinsulinemia rapidly increases human muscle microvascular perfusion but fails to increase muscle insulin clearance: evidence that a saturable process mediates muscle insulin uptake. Diabetes. 2007 Dec;56(12):2958-63. Epub 2007 Aug 24. — View Citation

Esteve E, Castro A, López-Bermejo A, Vendrell J, Ricart W, Fernández-Real JM. Serum interleukin-6 correlates with endothelial dysfunction in healthy men independently of insulin sensitivity. Diabetes Care. 2007 Apr;30(4):939-45. — View Citation

Hayaishi-Okano R, Yamasaki Y, Katakami N, Ohtoshi K, Gorogawa S, Kuroda A, Matsuhisa M, Kosugi K, Nishikawa N, Kajimoto Y, Hori M. Elevated C-reactive protein associates with early-stage carotid atherosclerosis in young subjects with type 1 diabetes. Diabetes Care. 2002 Aug;25(8):1432-8. — View Citation

Inyard AC, Clerk LH, Vincent MA, Barrett EJ. Contraction stimulates nitric oxide independent microvascular recruitment and increases muscle insulin uptake. Diabetes. 2007 Sep;56(9):2194-200. Epub 2007 Jun 11. — View Citation

Joannides R, Haefeli WE, Linder L, Richard V, Bakkali EH, Thuillez C, Lüscher TF. Nitric oxide is responsible for flow-dependent dilatation of human peripheral conduit arteries in vivo. Circulation. 1995 Mar 1;91(5):1314-9. — View Citation

Johnstone MT, Creager SJ, Scales KM, Cusco JA, Lee BK, Creager MA. Impaired endothelium-dependent vasodilation in patients with insulin-dependent diabetes mellitus. Circulation. 1993 Dec;88(6):2510-6. — View Citation

Keske MA, Clerk LH, Price WJ, Jahn LA, Barrett EJ. Obesity blunts microvascular recruitment in human forearm muscle after a mixed meal. Diabetes Care. 2009 Sep;32(9):1672-7. doi: 10.2337/dc09-0206. Epub 2009 Jun 1. — View Citation

Krolewski AS, Kosinski EJ, Warram JH, Leland OS, Busick EJ, Asmal AC, Rand LI, Christlieb AR, Bradley RF, Kahn CR. Magnitude and determinants of coronary artery disease in juvenile-onset, insulin-dependent diabetes mellitus. Am J Cardiol. 1987 Apr 1;59(8):750-5. — View Citation

Laakso M, Edelman SV, Brechtel G, Baron AD. Decreased effect of insulin to stimulate skeletal muscle blood flow in obese man. A novel mechanism for insulin resistance. J Clin Invest. 1990 Jun;85(6):1844-52. — View Citation

Ladeia AM, Stefanelli E, Ladeia-Frota C, Moreira A, Hiltner A, Adan L. Association between elevated serum C-reactive protein and triglyceride levels in young subjects with type 1 diabetes. Diabetes Care. 2006 Feb;29(2):424-6. — View Citation

Libby P, Nathan DM, Abraham K, Brunzell JD, Fradkin JE, Haffner SM, Hsueh W, Rewers M, Roberts BT, Savage PJ, Skarlatos S, Wassef M, Rabadan-Diehl C; National Heart, Lung, and Blood Institute; National Institute of Diabetes and Digestive and Kidney Diseases Working Group on Cardiovascular Complications of Type 1 Diabetes Mellitus. Report of the National Heart, Lung, and Blood Institute-National Institute of Diabetes and Digestive and Kidney Diseases Working Group on Cardiovascular Complications of Type 1 Diabetes Mellitus. Circulation. 2005 Jun 28;111(25):3489-93. — View Citation

Llauradó G, Ceperuelo-Mallafré V, Vilardell C, Simó R, Freixenet N, Vendrell J, González-Clemente JM. Arterial stiffness is increased in patients with type 1 diabetes without cardiovascular disease: a potential role of low-grade inflammation. Diabetes Care. 2012 May;35(5):1083-9. doi: 10.2337/dc11-1475. Epub 2012 Feb 22. — View Citation

Llauradó G, Simó R, Villaplana M, Berlanga E, Vendrell J, González-Clemente JM. Can augmentation index substitute aortic pulse wave velocity in the assessment of central arterial stiffness in type 1 diabetes? Acta Diabetol. 2012 Dec;49 Suppl 1:S253-7. doi: 10.1007/s00592-012-0433-y. Epub 2012 Oct 2. — View Citation

Lockhart CJ, Agnew CE, McCann A, Hamilton PK, Quinn CE, McCall DO, Plumb RD, McClenaghan VC, McGivern RC, Harbinson MT, McVeigh GE. Impaired flow-mediated dilatation response in uncomplicated Type 1 diabetes mellitus: influence of shear stress and microvascular reactivity. Clin Sci (Lond). 2011 Aug;121(3):129-39. doi: 10.1042/CS20100448. — View Citation

Miyaki A, Maeda S, Yoshizawa M, Misono M, Saito Y, Sasai H, Endo T, Nakata Y, Tanaka K, Ajisaka R. Effect of weight reduction with dietary intervention on arterial distensibility and endothelial function in obese men. Angiology. 2009 Jun-Jul;60(3):351-7. doi: 10.1177/0003319708325449. Epub 2008 Nov 19. — View Citation

Moncada S, Higgs A. The L-arginine-nitric oxide pathway. N Engl J Med. 1993 Dec 30;329(27):2002-12. Review. — View Citation

Nagaoka T, Kuo L, Ren Y, Yoshida A, Hein TW. C-reactive protein inhibits endothelium-dependent nitric oxide-mediated dilation of retinal arterioles via enhanced superoxide production. Invest Ophthalmol Vis Sci. 2008 May;49(5):2053-60. doi: 10.1167/iovs.07-1387. — View Citation

Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO 3rd, Criqui M, Fadl YY, Fortmann SP, Hong Y, Myers GL, Rifai N, Smith SC Jr, Taubert K, Tracy RP, Vinicor F; Centers for Disease Control and Prevention; American Heart Association. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003 Jan 28;107(3):499-511. — View Citation

Qamirani E, Ren Y, Kuo L, Hein TW. C-reactive protein inhibits endothelium-dependent NO-mediated dilation in coronary arterioles by activating p38 kinase and NAD(P)H oxidase. Arterioscler Thromb Vasc Biol. 2005 May;25(5):995-1001. Epub 2005 Feb 17. — View Citation

Rattigan S, Clark MG, Barrett EJ. Acute vasoconstriction-induced insulin resistance in rat muscle in vivo. Diabetes. 1999 Mar;48(3):564-9. — View Citation

Rossi R, Cioni E, Nuzzo A, Origliani G, Modena MG. Endothelial-dependent vasodilation and incidence of type 2 diabetes in a population of healthy postmenopausal women. Diabetes Care. 2005 Mar;28(3):702-7. — View Citation

Schalkwijk CG, Poland DC, van Dijk W, Kok A, Emeis JJ, Dräger AM, Doni A, van Hinsbergh VW, Stehouwer CD. Plasma concentration of C-reactive protein is increased in type I diabetic patients without clinical macroangiopathy and correlates with markers of endothelial dysfunction: evidence for chronic inflammation. Diabetologia. 1999 Mar;42(3):351-7. — View Citation

Schauer IE, Snell-Bergeon JK, Bergman BC, Maahs DM, Kretowski A, Eckel RH, Rewers M. Insulin resistance, defective insulin-mediated fatty acid suppression, and coronary artery calcification in subjects with and without type 1 diabetes: The CACTI study. Diabetes. 2011 Jan;60(1):306-14. doi: 10.2337/db10-0328. Epub 2010 Oct 26. — View Citation

Schram MT, Chaturvedi N, Schalkwijk CG, Fuller JH, Stehouwer CD; EURODIAB Prospective Complications Study Group. Markers of inflammation are cross-sectionally associated with microvascular complications and cardiovascular disease in type 1 diabetes--the EURODIAB Prospective Complications Study. Diabetologia. 2005 Feb;48(2):370-8. Epub 2005 Feb 4. — View Citation

Scognamiglio R, Negut C, De Kreutzenberg SV, Tiengo A, Avogaro A. Postprandial myocardial perfusion in healthy subjects and in type 2 diabetic patients. Circulation. 2005 Jul 12;112(2):179-84. Epub 2005 Jul 5. — View Citation

Soedamah-Muthu SS, Fuller JH, Mulnier HE, Raleigh VS, Lawrenson RA, Colhoun HM. All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999. Diabetologia. 2006 Apr;49(4):660-6. Epub 2006 Jan 24. — View Citation

Steinberg HO, Brechtel G, Johnson A, Fineberg N, Baron AD. Insulin-mediated skeletal muscle vasodilation is nitric oxide dependent. A novel action of insulin to increase nitric oxide release. J Clin Invest. 1994 Sep;94(3):1172-9. — View Citation

Steinberg HO, Chaker H, Leaming R, Johnson A, Brechtel G, Baron AD. Obesity/insulin resistance is associated with endothelial dysfunction. Implications for the syndrome of insulin resistance. J Clin Invest. 1996 Jun 1;97(11):2601-10. — View Citation

Sugawara J, Otsuki T, Tanabe T, Hayashi K, Maeda S, Matsuda M. Physical activity duration, intensity, and arterial stiffening in postmenopausal women. Am J Hypertens. 2006 Oct;19(10):1032-6. — View Citation

Sundell J, Rönnemaa T, Laine H, Raitakari OT, Luotolahti M, Nuutila P, Knuuti J. High-sensitivity C-reactive protein and impaired coronary vasoreactivity in young men with uncomplicated type 1 diabetes. Diabetologia. 2004 Nov;47(11):1888-94. Epub 2004 Nov 24. — View Citation

Szmitko PE, Wang CH, Weisel RD, de Almeida JR, Anderson TJ, Verma S. New markers of inflammation and endothelial cell activation: Part I. Circulation. 2003 Oct 21;108(16):1917-23. Review. — View Citation

Verma S, Buchanan MR, Anderson TJ. Endothelial function testing as a biomarker of vascular disease. Circulation. 2003 Oct 28;108(17):2054-9. Review. — View Citation

Vincent MA, Barrett EJ, Lindner JR, Clark MG, Rattigan S. Inhibiting NOS blocks microvascular recruitment and blunts muscle glucose uptake in response to insulin. Am J Physiol Endocrinol Metab. 2003 Jul;285(1):E123-9. — View Citation

Vincent MA, Clerk LH, Lindner JR, Klibanov AL, Clark MG, Rattigan S, Barrett EJ. Microvascular recruitment is an early insulin effect that regulates skeletal muscle glucose uptake in vivo. Diabetes. 2004 Jun;53(6):1418-23. — View Citation

Vincent MA, Clerk LH, Lindner JR, Price WJ, Jahn LA, Leong-Poi H, Barrett EJ. Mixed meal and light exercise each recruit muscle capillaries in healthy humans. Am J Physiol Endocrinol Metab. 2006 Jun;290(6):E1191-7. — View Citation

Vincent MA, Dawson D, Clark AD, Lindner JR, Rattigan S, Clark MG, Barrett EJ. Skeletal muscle microvascular recruitment by physiological hyperinsulinemia precedes increases in total blood flow. Diabetes. 2002 Jan;51(1):42-8. — View Citation

Westerbacka J, Uosukainen A, Mäkimattila S, Schlenzka A, Yki-Järvinen H. Insulin-induced decrease in large artery stiffness is impaired in uncomplicated type 1 diabetes mellitus. Hypertension. 2000 May;35(5):1043-8. — View Citation

Widlansky ME, Gokce N, Keaney JF Jr, Vita JA. The clinical implications of endothelial dysfunction. J Am Coll Cardiol. 2003 Oct 1;42(7):1149-60. Review. — View Citation

Zhang L, Vincent MA, Richards SM, Clerk LH, Rattigan S, Clark MG, Barrett EJ. Insulin sensitivity of muscle capillary recruitment in vivo. Diabetes. 2004 Feb;53(2):447-53. — View Citation

* Note: There are 58 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Augmentation Index-Change from baseline	measured at baseline and 24 weeks	24 weeks
Secondary	Flow Mediated Dilation-Change from baseline	measured at baseline and 24 weeks	24 weeks
Secondary	Pulse Wave Velocity-Change from baseline	measured at baseline and 24 weeks	24 weeks
Secondary	Post Ischemic Flow Velocity-Change from baseline	measured at baseline and 24 weeks	24 weeks
Secondary	Insulin Sensitivity-Change from baseline	measured by euglycemic insulin clamp at baseline and 24 weeks	24 weeks
Secondary	Microvascular Blood Volume-Change from baseline	measured at baseline and 24 weeks	24 weeks