Efficacy of Educational Nutrition and Exercise on the Regulation of Appetite Through Exosomes in Type 2 Diabetics (APETEX)

Efficacy of Educational Nutrition and Exercise on the Regulation of Appetite Through Exosomes in Type 2 Diabetics

Efficacy of a Nutritional Education Strategy and Role of Physical Exercise on the Regulation of Appetite and Body Composition Through the Profile of Exosomes in Type 2 Diabetics (The APETEX Project)

We hypothesize that the combination of a nutritional education intervention with a physical exercise program improves appetite regulation mediated by exosomes in people with Type 2 Diabetes Mellitus (T2DM), leading to better glycaemia/insulinaemia levels, reduction of body fat mass and quality of life. The project is a randomized controlled clinical trial in 120 participants with T2DM and obesity, which aims to determine the efficacy of a nutritional education program and the role of physical exercise type on health related variables. The participants will be of both sexes with age between 40 and 55 years, belonging to the Province of Cádiz. The design has two 12-week interventions; the main factor has 2 levels: participants who receive the nutritional education (EDU) and controls (CG); the second factor has 3 levels: high-intensity interval training (HIIT), moderate intensity continuous training (MICT), and controls (INACT). Therefore, participants will be randomized into 6 groups (n=20), adjusted by gender (≈50% in each group): EDU+HIIT, EDU+MICT, EDU+INACT, CG+HIIT, CG+MICT, CG+INACT. The outcome variables, which will be measured before and after the intervention, will include: dietary intake assessment, physical activity assessment, quality of life, blood samples, emotional reactivity to food images, blood pressure, appetite assessment, body composition and fluids, basal metabolism, maximal fat oxidation test and cardiorespiratory fitness.

Approximately 500 million people have Type 2 Diabetes Mellitus (T2DM) in 2018 and it is expected to increase between 20% and 50% over the next 10 years. T2DM is also called non-insulin-dependent or adult-onset, and it results from the body's ineffective use of insulin, being the result of excess body weight and physical inactivity. Diabetes is the 7 leading cause of death by increasing the risks of cardiovascular and other diseases, many of which (43%) occur prematurely and are largely preventable through adoption of policies to create supportive environments for healthy lifestyles. Therefore, improving the implementation of health-related education programs through nutrition and physical exercise is a key tool for behaviour change. The combination of physical exercise and nutritional counselling is known to improve the impact on both body composition and health in general population and in T2DM; however, the adherence of those programs is compromised and even if the complete intervention is performed by the patient, we can find non-responders. The underlying mechanisms that determine the impact of educational program focused on healthy lifestyles could be explained by molecular and physiological responses to the interventions. In this sense, hormones that regulate appetite and exerkines could impact on food preference, decision making, and in the exercise impact on appetite, consequently, modifying dietary intake, body composition and health. Exosomes (EX) have been considered as novel and potent vehicles of intercellular communication and exert the remarkable effects on lipid metabolism, including the synthesis, transportation and degradation of the lipid. EX have been proposed as a mechanism for the physiological effects of physical exercise in patients with T2DM. According to previous scientific research, we hypothesize that the combination of a nutritional education intervention with a physical exercise program improves appetite regulation mediated by exosomes in people with T2DM, leading to better glycaemia/insulinaemia levels, reduction of body fat mass and quality of life. The project is a randomized controlled clinical trial in 120 participants with T2DM and obesity, which aims to determine the efficacy of a nutritional education program and the role of physical exercise type on health related variables. The participants will be of both sexes with age between 40 and 55 years, belonging to the Province of Cádiz. The design has two 12-week interventions; the main factor has 2 levels: participants who receive the nutritional education (EDU) and controls (CG); the second factor has 3 levels: high-intensity interval training (HIIT), moderate intensity continuous training (MICT), and controls (INACT). Therefore, participants will be randomized into 6 groups (n=20), adjusted by gender (≈50% in each group): EDU+HIIT, EDU+MICT, EDU+INACT, CG+HIIT, CG+MICT, CG+INACT. The outcome variables, which will be measured before and after the intervention, will include: dietary intake assessment, physical activity assessment, quality of life, blood samples, emotional reactivity to food images, blood pressure, appetite assessment, body composition and fluids, basal metabolism, maximal fat oxidation test and cardiorespiratory fitness.

Maximal Fat Oxidation, Nutritional counselling, Insulin Sensitivity, Appetite regulation, High Interval Intensity Training

Participants who do not receive neither nutritional education nor exercise program. They will be instructed to maintain their normal life habits with respect to physical activity and diet.

Participants who do not receive nutritional education but are enrolled in a moderate-intensity continuous training exercise program.

Participants who do not receive nutritional education but are enrolled in a high-intensity interval training exercise program.

Participants who receive nutritional education and are enrolled in a moderate-intensity continuous training exercise program.

Participants who receive nutritional education and are enrolled in a high-intensity interval training exercise program.

The education intervention will consist of individual nutritional counselling. The nutritional education program will be conducted every 2 weeks for 12 consecutive weeks, with 20-min counselling sessions by an experienced nutritionist. Participants will be provided with an introduction (in an easy-to-understand manner) regarding the association between T2DM, gut microbiome and dietary habits. Firstly, the diet of the patient should be analysed, to determine which aspects can be improved, such as, total calories intake, amount and types of carbohydrates (highlighting the relevance of fibre), etc. Moreover, some suggestions about the combination of foods and culinary technical in order to manage the glycaemic index of foods will be provided. Finally, those pattern of the Mediterranean diet and some qualitative aspects and aids (as the size of the plat or avoid having the food platter on the table) will be taught the patients.

3 sessions per week in a cycle ergometer, with 1-2 days off between sessions, during a total of 12 weeks under the supervision of a personal trainer. HIIT program will consist of 3-5 series of 1 min duration at 90-130% of its maximum power (determined in the first training session), with 90 seconds of rest between sets (estimated total time of the session: 10 minutes). Depending on the number of training session, the load and the series will increase up to 40% more than the maximum load.

3 sessions per week in a cycle ergometer, with 1-2 days off between sessions, during a total of 12 weeks under the supervision of a personal trainer. MICT program will consist of sessions of approximately ˜45 min of moderate aerobic exercise (at the intensity at which the maximal fat oxidation was achieved in the laboratory test) in cycle ergometer.

Glucose and insulin concentrations will be assessed from blood samples in a fasted state of at least 8 hours. They will be determined using the ELISA technique. The HOMA-IR (Homeostatic Model Assessment for Insulin Resistance) insulin sensitivity index will be calculated.

From a blood sample in a fasted state of at least 8 hours. Exosomes will be isolated from plasma using an exoEasy Maxi kit (QIAGEN GmbH) according to the manufacturer's protocol. The quality and quantity of eluted vesicles will be assessed by biochemical analysis for identifying nucleic acids, proteins, lipids, cytokines, transcription factor receptors, and other bioactive substances.

Total RNA content will be assessed in a blood sample in a fasted state of at least 8 hours. RNA extraction will be performed from the EX using the Qiagen miRNeasy kit (Qiagen, Hilden) according to the manufacturer's instructions. RNA isolation will be performed on RNeasy MinElute UCP columns according to the manufacturer's recommendations. For quantification and identification of total RNA.

From a blood sample in a fasted state of at least 8 hours the appetite-regulating hormones will be assessed. Determined by means of the ELISA technique, including Gastric Inhibitory Polypeptide, Glucagon-like peptide 1, Cholecystokinin , AGRP and Neuropeptide Y. The concentration of hormones will be assessed.

Task of emotional reactivity to food images will be measured a high-density EEG system (Electrical Geodesics Inc) will be used, which will use 128-channel caps (HydroCel Sensor Net System, EGI, Inc, Eugene OR) with ultra-fast placement, and will be recorded brain activity in a state of rest and during the performance of a cognitive task of visual and attentional type. The images will be presented on a 15 '' monitor and will be divided into three blocks between which the participants can have a break. The stimuli will be extracted from the International Affective Picture System battery (Lang et al., 2008). Images will include over 200 images of foods with high calorie content (eg, cake, potato chips, roast beef and chocolate, etc.), or low calorie content (vegetables, fruit, etc.) They will also include non-food images associated with the animal category or inanimate objects.

Since appetite feeling modulate nutritional behaviour, the evaluation of appetite among the intervention groups can improve the quality of the study from a comprehensive perspective. After a period of 8-10 hours of fasting, an analogue visual scale (AVS) will be completed in order to measure the appetite felt by the participant in the morning.

Body composition will be estimated using a multifrequency bioimpedance of 8 electrodes previously validated (TANITAMC780MA). The calculation of impedance can estimate the fat mass and fat-free mass in kilograms. The patients will wear light clothing and will assume a posture in accordance with the manufacturers' instructions. Other previous considerations will be followed 24 hours before the measure: (i) to refrain from vigorous exercise, (ii) to take alcoholic drinks, (iii) to take energy drinks, and (iv) to be in a fasting state for at least 8 hours. Hydration status will be controlled through a urine color scale from clear to dark during the 7 days before assessment for adjusting variables.

Dietary intake assessment by trained surveyors in a personal interview, using a Food Frequency Questionnaire (FFQ). The FFQ has been previously validated in Mediterranean population of Spain, and provides qualitative frequency of consumption over the last year. In addition, a semi-quantitative analysis of total energy, macro and micro nutrients will be performed. The results will be analysed through the DIAL® software for Windows, version 3.7.1.0, estimating the average of total energy in kilocalories, macro, and micro nutrients in grams for each participant.

Dietary intake assessment by trained surveyors in a personal interview, using three 24h dietary recalls (24HR). The results will be analysed through the DIAL® software for Windows, version 3.7.1.0, estimating the average of total energy in kcal, macro, and micro nutrients in grams for each participant.

Physical activity assessment will be carried out through GT3X+ accelerometers (direct method) at wrist during 7-consecutive days. The data generated by the accelerometers will be analysed by using ActiLife 6.6.2 software (ActiGraph, Florida; USA), using Freedson (1998) cut points for adults and Choi's validation. Moreover, participants will complete the International Physical Activity Questionnaire Short Version (IPAQ-SF) (indirect method) previously validated in Spain.

Physical activity assessment will be carried out through GT3X+ accelerometers (direct method) at wrist during 7-consecutive days. The data generated by the accelerometers will be analysed by using ActiLife 6.6.2 software (ActiGraph, Florida; USA), using Freedson (1998) cut points for adults and Choi's validation. Moreover, participants will complete the International Physical Activity Questionnaire Short Version (IPAQ-SF) (indirect method) previously validated in Spain.

Physical activity assessment will be estimated by the participant's self-reported International Physical Activity Questionnaire Short Version (IPAQ-SF) previously validated in Spain. The IPAQ-SF calculates the sedentary time, moderate and vigorous activity time in minutes per week.

Basal Metabolism will be assessed to determine the Resting Fat Oxidation of each participant before and after the 12-week intervention, since its importance as a health indicator and relationship with obesity. Therefore, Oxygen uptake (VO2), carbon dioxide production (VCO2) will be registered at resting conditions on a bed in a supine position during 30 min. Resting indirect calorimetry will be measured using a gas analyser of an open circuit, Jaeger MasterScreen CPX® (CareFusion, San Diego, USA). Heart Rate will be measured continuously over the test with Polar Team 2 (Polar Electro Inc., Lake Success, NY). Resting Fat Oxidation in grams per minute will be calculated by the indirect equation proposed by Frayn.

Maximal fat oxidation test (MFO) to determine the maximal fat oxidation during exercise (MFO), a gradual test on cycloergometer (Lode Excalibur, Netherlands) will be performed. The test will begin with a load of 15Watts, increasing 15Watts every 3 minutes until the respiratory quotient reaches a stable value of 1 or higher. Throughout the test a cadence of 80 r.p.m. will be maintained. Calculation in the base of expired gases will be made for the estimation of grams per minute of fat oxidation.

Maximum VO2 test: To determine the maximal oxygen consumption (VO2max) during exercise in liters per minute, a gradual test on cycloergometer (Lode Excalibur, Netherlands) will be performed. The gas exchange will be measured by Jaeger MasterScreen CPX® (CareFusion, San Diego, USA)The test will be continuing the MFO from the load when the respiratory quotient reaches a stable value of 1 or higher. Once this point is reached, 15W increments will occur every minute until exhaustion is reached, until achieving the VO2max. Throughout the test a cadence of 80 r.p.m. will be maintained. Heart rate will be recorded in beats per minute.

Inclusion Criteria: Nonsmoking Non-alcoholic (<3 standard drinks per day) Body mass index >25 kg/m maintaining the habitual dietary patterns without a body mass reduction higher than 2% during the last 6 months Not being insulin dependent Absence of injury, disease or disability or other known medical condition which could affect the ability to successfully participate in physical exercise tests Absence of cardiovascular disease (angina, peripheral or cerebro-vascular disease, etc.). Absence of neurologic and psychiatric diseases. Absence of respiratory diseases (pulmonary hypertension, COPD, etc.). Absence of other metabolic diseases (hyper/hypo parathyroidism, hyper/hypothyroidism, Cushing's disease, Type 1 diabetes, etc.) Absence of active inflammatory bowel disease Absence of kidney disease Absence of tumours Absence of coagulation dysfunction Not under treatment with medications k known to affect glucose metabolism, recent steroid treatment (within 6 months), or hormone replacement therapy Be able to understand a communication in Spanish or English. Exclusion Criteria: They do not attend more than 2 or 4 consecutive sessions of nutritional counselling or physical training respectively. The lose more than 4 or 6 sessions in total of nutritional counselling or physical training respectively.