The Impact of Pectin Supplementation on Systematic Inflammation Pathway, Gut Microbiome, and Metabolic Health in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

The Impact of Pectin Supplementation on Systematic Inflammation Pathway, Gut Microbiome, and Metabolic Health in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Randomised, Placebo-Controlled, Dietary Intervention Study

The goal of this clinical trial is to learn if daily supplementation with Low-methoxy (LM) pectin (polysaccharides extracted from citrus peels), which are commonly found in the UK diet (not pharmacological agents), can reduce systemic inflammation and improve gut microbiota composition in adults recently diagnosed with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). The main question it aims to answer is:

-How does dietary Low-methoxy (LM) pectin supplementation affect systematic inflammation pathways such as those mediated by gut microbiota composition and what are the impacts on general metabolic indicators in individuals with MASLD?

Researchers will compare a group taking 15g of LM-pectin with 10g of cocoa powder to a placebo group receiving 10g of placebo with 10g of cocoa powder to see if LM-pectin has measurable effects on inflammation and gut microbiota.

Participants will:

• Take a daily supplement for 6 weeks: either 15g of LM-pectin with 10g of cocoa powder (intervention), or 10g of placebo with 10g of cocoa powder (control)
• Provide stool and fasting blood samples before and after the intervention
• Undergo anthropometric measurements (weight, height, waist/hip ratio, and blood pressure)
• Complete a case report form (CRF) including demographics and health/medical history
• Undergo a FibroScan™ to assess liver health
• (Optional) Participate in MRI scans to evaluate gut permeability

Primary Objective:

This research aims to study the effects of daily ingestion of LM pectin on inflammation pathways by measuring the blood inflammatory markers associated with physiological processes (TNFα, IL-6, IL-10, IFNᵞ, C - reactive protein, Zonulin (Haptoglobulin), IL-1β).

Secondary Objectives:

1. Assessment of changes in anthropometric measures.
2. Assessment of changes in general metabolic indicators, such as fasting blood glucose and other blood-based markers relevant to MASLD (e.g., CK18-M30, CK18-M65, PROC3, Enhanced Liver Fibrosis (ELF), NIS2+™, YKL-40, microRNA miR-34a-5p, liver-associated enzymes such as Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), gamma-glutamyl transferase (GGT), Alkaline Phosphatase (ALP)), bilirubin levels, lipid profiles, and platelet counts.
3. Exploration of changes in gut microbiome composition.
4. Exploration of modifications in non-invasive physiological assessments linked to liver characteristics, such as fat content and stiffness through controlled attenuation parameter (CAP) and transient elastography.
5. Observation of alteration in fat in liver and other surrounding abdominal organs through Dixon MRI sequence in patients who will agree to have 2 MRI scans.
6. Validation of MRI measures (T2*) as a tool to measure gut permeability among MASLD patients and investigation of changes in gut permeability in participants undergoing two MRI scans.
7. Investigation the presence of gene variants such as MUC2, encoding Mucin protein, that are associated with gut permeability.

Inclusion Criteria:

Inclusion criteria for the main study:

• Patients with clinical diagnosis of MASLD (formerly termed non-alcoholic fatty liver disease (NAFLD)), having assessment suggesting that liver fat > 5% (e.g. histological evidence or/ and Transient Elastography using Controlled Attenuation Parameter (CAP)- FibroScan™ in the past month and/or liver imaging (such as ultrasound, computerized tomography (CT) or magnetic resonance imaging (MRI)).
• Participants willing and able to give informed consent for participation in the study.
• Participants aged ≥18 years who have a body mass index (BMI) between 18.5 and 39.9 kg/m2 and stable weight (weight gain or loss ≤ 3kg) for the past 3 months.
• For diabetic participants: controlled blood glucose levels Haemoglobin A1C (HbA1c) <7.0% (<53 mmol/mol) [1].
• Able to undergo CAP-FibroScan™.

Inclusion criteria for healthy participants who will have MRI scans:

• Participants willing and able to give informed consent for participation in the study.
• Participants aged ≥18 years.
• participants with CAP<250 kpa<8kP by a FibroScan™ within the past 6 months.

Exclusion Criteria:

Exclusion criteria for the main study:

• Have allergy toward soya, milk or chocolate.
• Have allergy toward pectin.
• Participants on vegan diet.
• Have eating disorders or difficulties or gastrointestinal conditions e.g. malabsorptive conditions such as coeliac, Irritable Bowel Syndrome (IBS) or Inflammatory Bowel Disease (IBD) or gastroparesis.
• Have chronic malnutrition condition.
• History of major surgery which potentially limits participation or completion of the study.
• History of previous intestinal surgery known to affect food intake or digestive function, including bariatric surgery.
• Use of antibiotics, antifungal medications, probiotics or prebiotics 90 days before the start of the study.
• Are taking the following medications: immunosuppressants, amiodarone and/or perhexiline.
• Are currently following or anticipated to commence a specialised commercially available weight loss diet and/or program or concomitant use of any weight loss medication or herbal weight loss products.
• History of side effects towards probiotics or prebiotics.
• History or current psychiatric illness.
• History or current neurological condition (e.g. epilepsy).
• Participants with other liver abnormalities.
• Evidence of monogenic metabolism diseases such as Lysosomal acid lipase deficiency (LALD), Wilson disease, Hypobetalipoproteinemia, or inborn errors of metabolism.
• Have had a weight change exceeding 3 kg within 3 months.
• Uncontrolled diabetes, active malignancy, or chronic infections.
• Having symptoms of active infection.
• Excessive alcohol intake defined as self-reported intakes greater than 21 units per week in men, and 14 units per week in women.
• Participants who are pregnant, breast feeding or actively planning pregnancy will be excluded from the study.
• Participation in any other trial in the last 3 months.

Exclusion criteria for healthy volunteers MRI scans and patients optional MRI scans:

• Contraindications for MRI scanning: having pacemakers, defibrillators, neurostimulators, prohibited medical implants, and foreign bodies (e.g. bullets, shrapnel, metal slivers), history of metallic foreign body in eye(s) and penetrating eye injury that could present a risk during an MRI scan.
• Difficulty breathing or inability to lie flat, as well as conditions that could worsen under stress (such as anxiety or panic disorders, claustrophobia, uncontrolled hypertension, or seizure disorders) severe enough to prevent undergoing an MRI.