The effects of plant sterol and plant stanol ester enriched foods on liver inflammation in subjects at risk to develop NASH

As the prevalence of obesity is reaching epidemic proportions, the prevalence
of non-alcoholic fatty liver disease (NAFLD), including non-alcoholic
steatohepatitis (NASH), increases concomitantly and becomes a major global
health hazard. Successful pharmacological interventions to treat or prevent
NASH are not available and so far only weight loss has clear benefits, but
sustained weight-loss is difficult to achieve on the longer-term. We recently
demonstrated in mice that plant sterol and stanol ester consumption inhibited
the development of liver inflammation. Moreover, Javanmardi and co-workers
recently observed reduced plasma concentrations of Alanine Transaminase (ALT)
and Aspartate Transaminase (AST) after daily plant sterol consumption (1.6 g/d)
for 6 weeks in a population of adult NAFLD patients. In the current study, we
propose to evaluate the effect of long-term consuming plant sterol or plant
stanol esters on ALT concentrations in subjects who are at risk to develop
NASH. Furthermore, we want to demonstrate the effect of plant sterol and plant
stanol consumption on other parameters reflecting liver health, such as
cathepsin-D, liver fat and liver insulin sensitivity.

To assess the effect of consuming plant sterol or plant stanol esters (3
grams/day) for 6 months on ALT concentrations in subjects with elevated ALT
concentrations, i.e. who are at risk to develop NASH.

This study is a randomized, placebo-controlled, double blinded pilot study with
a run-period of 2 weeks, an intervention period of 6 months and a wash-out
period of 1 month.

All subjects will start a run-in period of two weeks during which they consume
daily 20 grams of control margarine after which they will be randomly allocated
to consume 20 grams control margarine or plant sterol or plant stanol enriched
margarine on a daily basis for a period of 6 months.

During a screening visit, body weight, body height and blood pressure are
determined and a blood sample (5.5 mL) will be drawn. During the run-in period
of two weeks, subjects will receive 20g control margarine and during the
intervention period of 6 months they will be randomized to receive control,
plant sterol ester or plant stanol ester margarine. On 7 occasions a fasting
blood sample will be drawn (with a total of 195 mL) and at baseline and in week
26, samples for VOCs analysis will be taken, a FibroScan will be performed to
measure liver fat and liver stiffness, body composition will be determined and
retinal images will be taken. In a subgroup of 30 subjects, liver fat and liver
inflammation will be measured with MRS imaging at baseline and at the of
intervention in week 26. All subjects will be asked to fill out a food
frequency questionnaire two times and to keep a diary throughout the study and
body weight and blood pressure will be assessed on five occasions.
Venipuncture and insertion of a cannula can cause discomfort and possibly a
local haematoma or bruise. MRS and MRI are modern diagnostic tools that do not
imply significant risks (no ionizing radiation). In principle, all measurements
are routine in our metabolic research unit (MRUM) and are not expected to lead
to physical side effects. Total time investment spread-out over the study
participation will be approximately 6 hours or 34 hours (depending on the
subgroup), excluding travel time. Plant sterol and plant stanol enriched
products are commercially available and we therefore do not foresee any risks
related to the consumption of these food products