Trial Review

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Trial registered on ANZCTR


Registration number
ACTRN12619000739112
Ethics application status
Approved
Date submitted
10/05/2019
Date registered
17/05/2019
Date last updated
15/02/2022
Date data sharing statement initially provided
17/05/2019
Date results information initially provided
15/02/2022
Type of registration
Prospectively registered

Titles & IDs
Public title
What is the effect of increasing dietary resistant starch on gut health and immunity in HIV-positive adults in India and is a feeding trial feasible?
Scientific title
What is the effect of a dietary resistant starch intervention on the colonic luminal environment and HIV-related immunity and is a feeding trial feasible in HIV-positive adults in India?
Secondary ID [1] 298178 0
Nil known.
Universal Trial Number (UTN)
U1111-1233-1893
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
HIV 312758 0
Gastrointestinal dysbiosis 312759 0
Gastrointestinal symptoms 312760 0
Gut pathology syndrome 312763 0
Condition category
Condition code
Diet and Nutrition 311255 311255 0 0
Other diet and nutrition disorders
Oral and Gastrointestinal 311256 311256 0 0
Other diseases of the mouth, teeth, oesophagus, digestive system including liver and colon
Infection 311257 311257 0 0
Acquired immune deficiency syndrome (AIDS / HIV)
Inflammatory and Immune System 311258 311258 0 0
Other inflammatory or immune system disorders
Public Health 311259 311259 0 0
Other public health

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Feasibility pilot study comprising quantitative and qualitative sub-studies.

Quantitative:
Randomized two-by-two double crossover design, single-blinded feeding trial.
A dosage of 40 grams/day of resistant starch will be fed to participants as the 'study intervention'. Forty grams of resistant starch will be added to study foods as 95 grams of High Amylose Maize Starch (HAMS), the commercial food ingredient to be used. HAMS includes both digestible and non-digestible (resistant) fractions and will be incorporated into a study food of either flat bread or rice pudding, to be decided following palatability testing. A 'control intervention' of cornstarch will be used and is detailed below under 'Comparator / control treatment.'

In phase 1 of this crossover trial, participants will consume study foods incorporating the randomly assigned intervention on a daily basis for a 2 week period in addition to their habitual diet. All participants will then consume their habitual diet only for a 2 week period during the ‘washout period’ when outcome measures are expected to return to baseline (day 0) values. After the washout period, participants will cross over and consume study foods incorporating the other intervention on a daily basis for 2 weeks in addition to their habitual diet in phase 2. A further 2 week washout period will then be applied to all participants after which they will be randomized again to determine which study food will be consumed first in the second crossover using the same two study foods. The same crossover pattern as the first crossover will then apply but it will be based on this second randomization step to determine which study food is consumed first.

The study food interventions will be prepared and administered by the Principal Investigator who is a qualified dietitian and university doctoral student in conjunction with the Indian Field Assistant. The study foods will be delivered to the home of the participants for consumption daily during the intervention periods. In some circumstances, where it is more convenient for participants, the study food intervention will be provided at the HIV/ART clinic. Participants will be asked to consume the study food under observation by these study staff as a measure to encourage compliance. Any leftover portion not consumed will be weighed.

Qualitative:
Participants will also participate in 2 semi-structured interviews (individual or focus group) re: factors affecting compliance with the feeding study and dietary resistant starch intervention including perceptions about participation, study food, palatability and tolerability, adherence and side effects. Individual or focus group interviews will be conducted at the HIV clinic whenever possible. When not possible, interviews will be conducted at the home of the participant or another convenient location nominated by the participant. Interviews will be attended by a 2 person interview team where possible. The semi-structured interviews will be conducted immediately before the phase 1 intervention commences at baseline (day 0), at the end of the phase 2 intervention of the first crossover at day 43 and at the end of the final washout period of the second crossover period at day 112.
Intervention code [1] 314411 0
Treatment: Other
Comparator / control treatment
Cornstarch, which consists of digestible starch only, will be used as the 'control intervention' in this crossover trial and incorporated into study foods of the same type as those used for the 'study intervention'. The dosage of cornstarch to be incorporated into study foods will be equivalent to the digestible portion of the HAMS or 55 grams per day. Participants will be blinded to which starch they are consuming. Participants will consume the study foods containing cornstarch on a daily basis for 2 weeks according to the study design detailed above under 'Description of intervention(s) / exposure.'
Control group
Active

Outcomes
Primary outcome [1] 320015 0
Change in pH of stool samples, Supernatant pH will be measured using a pH meter (Mettler-Toledo Ltd.) on a scale of 1-14.
Timepoint [1] 320015 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [1] 370271 0
Change in acetate concentration of stool sample as mmol/L. To be measured by gas chromatography fitted with a flame ionisation detector.
Timepoint [1] 370271 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [2] 370272 0
Change in butyrate concentration of stool sample as mmol/L. To be measured by gas chromatography fitted with a flame ionisation detector.
Timepoint [2] 370272 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [3] 370273 0
Change in propionate concentration of stool sample as mmol/L. To be measured by gas chromatography fitted with a flame ionisation detector.
Timepoint [3] 370273 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [4] 370275 0
Alpha diversity of bacterial species in stool sample as measured by Operational Taxonomic Units (OTUs). This will involve the following steps:
DNA extraction will be performed using a Mo Bio PowerLyzer PowerSoil® 96 Well DNA isolation kit (Mo Bio Laboratories). DNA concentrations will be quantified fluorometrically with a Quant-iT dsDNA Assay kit (Life Technologies).
Following DNA extraction, quantitative PCR and gene amplicon sequencing will
be undertaken of the V4 hypervariable region of the bacterial 16S rRNA gene. An Illumina MiSeq platform will be utilized. Paired-end 16S rRNA gene amplicon sequence reads will be analysed with Quantitative Insights into Microbial Ecology (QIIME) software (v1.8.0).
Timepoint [4] 370275 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [5] 370276 0
Beta diversity of bacterial species as measured by Bray–Curtis dissimilarity index. This will involve the following steps:
DNA extraction will be performed using a Mo Bio PowerLyzer PowerSoil® 96 Well DNA isolation kit (Mo Bio Laboratories). DNA concentrations will be quantified fluorometrically with a Quant-iT dsDNA Assay kit (Life Technologies).
Following DNA extraction, quantitative PCR and gene amplicon sequencing will
be undertaken of the V4 hypervariable region of the bacterial 16S rRNA gene. An Illumina MiSeq platform will be utilized. Paired-end 16S rRNA gene amplicon sequence reads will be analysed with Quantitative Insights into Microbial Ecology (QIIME) software (v1.8.0).
Timepoint [5] 370276 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [6] 370277 0
Faecal calprotectin of stool samples as µgrams/gram.
Timepoint [6] 370277 0
Baseline will be measured at day 0 and then a further timepoint is included at the end of the final dietary intervention phase (Phase 4) at day 99.
Secondary outcome [7] 370278 0
Change in CD4+ T-cell count (cells/mm3) using flow cytometry of venous blood samples.
Timepoint [7] 370278 0
Days 0, 15, 43, 56, 71, 84 and 99 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [8] 370281 0
Change in HIV viral load . HIV viral load measured as copies per mL and determined by HIV Nucleic Acid Amplification Test of HIV RNA using PCR of venous blood samples.
Timepoint [8] 370281 0
Days 0, 15, 43, 56, 71, 84 and 99 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [9] 370282 0
Self-report measure for intensity of 'Loose Stools' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [9] 370282 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [10] 370285 0
Self-report measure for intensity of 'Diarrhoea' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [10] 370285 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [11] 370286 0
Self-report measure for intensity of 'Gas/bloating' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [11] 370286 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [12] 370287 0
Self-report measure for intensity of 'Abdominal pain' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [12] 370287 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [13] 370288 0
Self-report measure for intensity of 'Nausea' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [13] 370288 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [14] 370289 0
Self-report measure for intensity of 'Vomiting' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [14] 370289 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [15] 370290 0
Self-report measure for intensity of 'Lack of appetite' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [15] 370290 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [16] 370291 0
Self-report measure for intensity of 'Constipation' (from subset of the Revised Sign and Symptom Checklist for HIV (SSC-HIVrev) questionnaire measuring gastrointestinal symptoms) on a scale of 'Mild', 'Moderate' and 'Severe'.
Timepoint [16] 370291 0
Days 0, 15, 28, 43, 56, 71, 84, 99 and 112 where 'day 0' indicates the day preceding the first day (day 1) of phase 1 of the crossover study. On day 1, commencement of the first randomly-assigned feeding intervention will begin ('study intervention' or 'control intervention').
Secondary outcome [17] 370292 0
Total dietary intake of resistant starch (grams/day) as measured by a Food Frequency Questionnaire (FFQ).
Timepoint [17] 370292 0
Timepoints for the FFQ survey to measure dietary intake of resistant starch, reflect the end of each of the 4 dietary intervention phases as follows:
End of Phase 1: day 15;
End of Phase 2: day 43;
End of Phase 3: day 71;
End of Phase 4: day 99.
Secondary outcome [18] 370293 0
Themes arising from qualitative semi-structured interviews (individual or focus group) re: factors affecting compliance with the feeding study including perceptions about participation, study food, palatability and tolerability, adherence and side effects.

Specifically, the translator will produce a transcript of the audio recordings which will then be back-translated by another member of the Indian study team to check content accuracy (Lopez et al. 2008). A protocol will be used to establish translation rules for the study including defining allowable omissions and how to reflect non-verbal gestures or utterances (Clark et al. 2017). Data collection will continue until saturation is reached and no new data is emerging (Minichiello, 1990). In-depth interview data will be analysed and coded using open coding followed by focused coding approaches (Minichiello et al. 1990). This will be undertaken independently by both the study coordinator and another member of the research team prior to sharing of results. Discussion of any differences and associated rationale will resolve key theme allocation. If required, a third investigator will be consulted and this will be a member of the Indian team, given the Indian context of this study. SPSS and STATA will be used to examine any correlations between key themes arising from the qualitative data with quantitative measures from the study.
After the interviews and focus groups are completed, participants will be invited to check the summary report written by the research team. These reports will not identify participants by name or any other identifying factors.
Timepoint [18] 370293 0
A semi-structured interview will be conducted at baseline (day 0) and then also at the following timepoints:
End of second dietary intervention phase in first crossover period at day 43;
End of study at day 112.

This will enable the determination of any differences affected by the time period elapsed between the dietary intervention phase and the interview (i.e. day 43 is immediately following a dietary intervention phase and day 112 is immediately following a 2 week phase of normal diet.)

Eligibility
Key inclusion criteria
1.) HIV-positive adults aged 18 years or over on Anti Retroviral Therapy (ART); 2.) CD4+ T cell count more than 200 cells/mm3; 3.) No antibiotic usage within last 6 weeks.
Minimum age
18 Years
Maximum age
No limit
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
1.) Co-morbidities affecting the gastrointestinal tract such as Crohn’s Disease, Ulcerative Colitis. 2.) Current participation in other interventional studies; 3.) Pregnant or breastfeeding.

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Allocation is concealed. Central randomisation by computer to be utilised.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Simple randomisation using a randomisation table created by computer software (i.e. computerised sequence generation)
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?
The people receiving the treatment/s


Intervention assignment
Crossover
Other design features
Phase
Not Applicable
Type of endpoint/s
Efficacy
Statistical methods / analysis
The primary outcome measure (pH) determined the sample size calculation. Assuming an effect size of 0.4 based on prior data (Phillips et al. 1995) that also used a resistant starch intervention, a sample size of 20 participants would be required in order to determine significant change in pH attributable to the resistant starch intervention. Based on our own pilot data, the study team has assumed a correlation between the 4 measures (pre and post each treatment) for each participant of r=0.6 and a corresponding variance inflation factor=(1-0.6)/4=0.1 (Hsieh et al. 2003). Thirty participants will be recruited to allow for drop-outs.

The baseline/day 0 samples will act as the individual’s own control. Outcomes will be assessed using linear mixed effects models with Stata software (version 15.0). Food Frequency Questionnaires results will be quantified for resistant starch content by the study coordinator who is a qualified dietitian. Qualitative data gathered from the semi-structured interviews/focus groups will be analysed using NVivo software (version 12.1). SPSS and STATA will be used to examine any correlations between key themes arising from the qualitative data with the quantitative measures.

Recruitment
Recruitment status
Stopped early
Data analysis
Data collected is being analysed
Reason for early stopping/withdrawal
Other reasons/comments
Other reasons
Due to the COVID-19 pandemic and lockdown restrictions at the study site, recruitment to the study was halted early.
Date of first participant enrolment
Anticipated
1/07/2019
Actual
22/02/2020
Date of last participant enrolment
Anticipated
15/07/2019
Actual
13/05/2020
Date of last data collection
Anticipated
9/09/2019
Actual
2/09/2020
Sample size
Target
30
Accrual to date
Final
5
Recruitment outside Australia
Country [1] 21464 0
India
State/province [1] 21464 0
Odisha

Funding & Sponsors
Funding source category [1] 302717 0
University
Name [1] 302717 0
Flinders University of South Australia
Country [1] 302717 0
Australia
Primary sponsor type
University
Name
Flinders University of South Australia
Address
Flinders Drive
Bedford Park
South Australia
5042
Country
Australia
Secondary sponsor category [1] 302643 0
University
Name [1] 302643 0
All India Institute of Medical Sciences
Address [1] 302643 0
Sijua
Patrapada
Bhubaneswar
Odisha 751019
Country [1] 302643 0
India

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 303323 0
Southern Adelaide Clinical Human Research Ethics Committee
Ethics committee address [1] 303323 0
Southern Adelaide Local Health Network
Flinders Medical Centre, Ward 6C, Room 6A219
Flinders Drive
Bedford Park
South Australia
5042
Ethics committee country [1] 303323 0
Australia
Date submitted for ethics approval [1] 303323 0
04/02/2019
Approval date [1] 303323 0
29/03/2019
Ethics approval number [1] 303323 0
345.18

Summary
Brief summary
Residents of low and middle income countries often suffer from compromised nutritional status because of the sub-optimal water and sanitation setting which leads to repeated exposure to germs from the environment. Exposure to these germs can lead to a gut pathology syndrome, comprising the following:
> Damage to the lining of the gut;
> Nutrient malabsorption;
> ‘Translocation’ or movement of bacteria across the lining of the gut;
> Dysbiosis (disturbance of gut bacteria); and
> Inflammation.
The situation is more serious for immune-compromised individuals such as people living with HIV. Application of a cost-effective intervention that will augment traditional anti-retroviral therapy by repairing the damaged gut, facilitating increased absorption of nutrients, and improving HIV-related immunity will be a welcome adjunct therapy in this priority population. The anticipated benefit of adding resistant starch to HIV-treatment regimens is based on previous observations of favourable effects.

Study hypotheses: That adding resistant starch to the normal diet for 2 weeks will lead to improvements in the colon and HIV-related immunity and will be deemed tolerable by study participants.
Trial website
Trial related presentations / publications
Public notes
Ethics approval will also be secured from the Institutional Ethics Committee of the All India Institute of Medical Sciences Bhubaneswar.

Contacts
Principal investigator
Name 93274 0
Ms Elissa Kate Mortimer
Address 93274 0
College of Medicine and Public Health
Flinders University of South Australia
Flinders Drive
Bedford Park
South Australia
5042
Country 93274 0
Australia
Phone 93274 0
+61415216907
Fax 93274 0
Email 93274 0
[email protected]
Contact person for public queries
Name 93275 0
Ms Elissa Kate Mortimer
Address 93275 0
College of Medicine and Public Health
Flinders University of South Australia
Flinders Drive
Bedford Park
South Australia
5042
Country 93275 0
Australia
Phone 93275 0
+61415216907
Fax 93275 0
Email 93275 0
[email protected]
Contact person for scientific queries
Name 93276 0
Ms Elissa Kate Mortimer
Address 93276 0
College of Medicine and Public Health
Flinders University of South Australia
Flinders Drive
Bedford Park
South Australia
5042
Country 93276 0
Australia
Phone 93276 0
+61415216907
Fax 93276 0
Email 93276 0
[email protected]

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
All of the individual participant data collected during the trial, after de-identification.
When will data be available (start and end dates)?
Beginning 3 months and ending 5 years following main results publication.
Available to whom?
To be made available to anyone who wishes to access it.
Available for what types of analyses?
Any purpose.
How or where can data be obtained?
Unrestricted access via email request to Principal Investigator/Corresponding author.


What supporting documents are/will be available?

Doc. No.TypeCitationLinkEmailOther DetailsAttachment
2051Ethical approval  [email protected] 377554-(Uploaded-25-11-2020-15-50-11)-Study-related document.pdf
15087Study protocol  [email protected]
15088Informed consent form  [email protected] 377554-(Uploaded-29-07-2020-13-49-58)-Study-related document.pdf



Results publications and other study-related documents

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