SMART Diets for MASLD

Metabolic-dysfunction associated steatotic liver disease is defined as the presence of abnormal hepatic stored triglycerides (hepatic steatosis), with one or more of 5 cardiometabolic factors (increased body mass index or waist circumference, hyperglycemia, hypertriglyceridemia, or low HDL) and no other chronic liver disease. Pediatric hepatic steatosis is central to long-term metabolic and cardiovascular health because of the relation of hepatic steatosis to the development of other major diseases. Hepatic steatosis limits the normal metabolic role of insulin and plays a key role in the future development of the metabolic syndrome, and is the strongest predictor for the development of type 2 diabetes.

• Essential Amino Acids Supplementation intervention (Drug), also known as EAA, AMS2392: EAA supplement contains the following formulation: histidine, isoleucine, leucine, lysine, phenylalanine, threonine, and valine
• Low sugar diet (Other): The Low Sugar Diet uses the adapted and extended Social Cognitive Theory (SCT) guided low sugar intervention. The registered dietitian nutritionist (RDN) helps families to identify foods high in sugar and to identify acceptable replacements in order to remove foods and drinks high in free sugar from the home and replacement with low or no free sugar containing similar foods.

Primary outcomes

• Change in hepatic steatosis [Baseline to 24 weeks]: Change in hepatic steatosis by magnetic resonance imaging (MRI)

Secondary outcomes

• Change in fasting triglyceride [Baseline, 12 and 24 weeks]: Change in triglyceride in mg/dL
• Change in HDL [Baseline, 12 and 24 weeks]: Change in HDL mg/dL
• Change in VLDL-triglyceride [Baseline, 12 and 24 weeks]: Very-low-density-lipoprotein triglyceride
• Change in Waist circumference [Baseline, 12 and 24 weeks]: Change in Waist circumference in cm
• Change in body weight [Baseline, 12 and 24 weeks]: Change in weight in kilograms
• Change in BMI Z Score [Baseline, 12 and 24 weeks]: Change in body mass index z-score
• Change in Alanine Aminotransferase (ALT) [Baseline, 12 and 24 weeks]: Change in ALT
• Aspartate Aminotransferase (AST) [Baseline, 12 and 24 weeks]: Change in AST
• Gamma glutamyl transferase (GGT) [Baseline, 12 and 24 weeks]: Change in GGT
• Systolic blood pressure [Baseline, 12 and 24 weeks]: Change in systolic blood pressure mg/dL
• Diastolic blood pressure [Baseline, 12 and 24 weeks]: Change in diastolic blood pressure (mg/dL)
• Hemoglobin A1c [Baseline, 12 and 24 weeks]: Change in hemoglobin A1c
• HOMA-IR [Baseline, 12 and 24 weeks]: Change in homeostatic model assessment of insulin resistance (HOMA-IR)
• Adverse events [Baseline, 12 and 24 weeks]: Number of adverse events compared between arms of the study
• Percent responders [Baseline to 24 weeks]: Percent of participants who reduce hepatic steatosis in the group that start with low sugar diet compared to the group that starts with EAA intervention

Sex: All, ages: 11 Years to 17 Years

Inclusion Criteria:

* Children 11 to 17-years-old at the time of consenting
* Hepatic Steatosis by MRI greater than or equal to 8% on baseline MRI
* At least 1 of the following cardiometabolic risk factors: BMI greater than or equal to 85th percentile for age/sex or WC greater than 95th percentile, Abnormal cholesterol or triglyceride levels, Blood pressure BP greater than or equal to 95th percentile OR greater than or equal to 130/80 and/or signs of insulin resistance (Acanthosis Nigricans OR HOMA-IR of greater 2.0 and greater 2.6 in prepubertal and pubertal children, respectively, Fasting Insulin Level of 10 pIU/mL in prepubertal children and of 17 pIU/mL and 13 pIU/mL in pubertal girls and boys, respectively, OR Prediabetes)
* ALT greater than or equal to 40 U/L
* Currently consumes greater than or equal to 2 eight-ounce sugar drinks (or juice) per week.
* Patients of childbearing potential agrees to use adequate one or more effective methods of contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation.
* Patients who are taking medications that can affect insulin (e.g., metformin, corticosteroids), most be on a stable dosage for at least 3 months prior to enrollment of the trial.
* Written informed consent from parent or legal guardian, assent from child.

Exclusion Criteria:

* Patients with Diagnosed Type 2 or Type 1 Diabetes Mellitus (T2DM) or HbA1c of >6.5 mg/dL at baseline
* Patients diagnosed with or suspected to have a chronic liver disease other than MASLD by screening labs or evaluation (i.e autoimmune, viral). Screening labs are defined as: Hepatitis B surface antigen, Hepatitis C virus total antibody, IgG, ceruloplasmin, and alpha 1 antitrypsin phenotype.
* Patients unable to complete MRI or Labs required for the study.
* Current participation in another clinical trial
* Current participation in a weight loss program or obesity treatment program or clinic
* Cancer or history of cancer within 5 years
* Severe illness that required hospitalization in the last 60 days
* Use of medications known to cause liver steatosis (TPN, amiodarone, chronic oral steroids, etc.)
* Patients with implanted metal devices that are not compatible with magnetic resonance imaging (MRI).
* Intellectual disability or major psychiatric disorder limiting informed assent
* Clinical evidence of cirrhosis or advanced liver disease by any one of the following abnormal labs: (Hemoglobin less than 10 g/dL, White blood cell less than 3,500 cells/mm, Neutrophil count less than 1,500 cells/mm3 of blood, Platelets less than 130,000 cells/mm3 of blood, Direct bilirubin greater than 1.0 mg/dL)
* Elevated total bilirubin except if known to have Gilbert's syndrome and direct bilirubin in normal range.
* Albumin less than 3.2 g/dL
* A history of international normalized ratio (INR) greater than 1.4
* AST or ALT greater than 250 IU/dL.
* Compensated or decompensated cirrhosis with evidence of portal hypertension.
* Patients is pregnant or breastfeeding.
* Patients who have been enrolled in a recent clinical trial and had the last dose of investigational product within 30 days or 5 half-lives of the study drug, whichever is longer.

• Miriam B Vos, MD, MSPH, Principal investigator, Michigan State University

NIH grants: R61HL174736