Strengthening Bodies & Minds Through Knowledge
Fayad, Joseph MD FACP, FACG , Singh, A.K., Ph.D., Rubin Eliyahu MD, Jerome Schentag Pharm D, Fayad Christine, MA.
Abstract:
Trial of different composition and delivery systems of a benign food substance APHOELINE 1 delivered orally to stimulate the ileal hormones to elicit the body own signaling is reported. The response appears to be sufficient to standardize the stimulation of the ileal brake hormones. Some unusual effects of that stimulation included suppression of insulin resistance, improvement in blood glucose levels, and significant early improvement in liver enzymes and lipid levels. While these beneficial effects were sustained in short term experiments, further large scale clinical testing and longer term clinical studies will be needed to confirm the persistence of these effects.
Based on our open trials, the long term effect of the APHOELINE 1 formulation is an increase in energy levels, an unconscious awareness of the calorie intake and a resetting of appetite which then resulted in significant weight loss. Long term double-blind placebo controlled trials are being planned.
Introduction:
GI segment-derived hormones were first localized along the intestinal tract of dogs and humans in the early 1970s (1, 2). It was apparent that these hormones were meant as controllers to prevent loss of nutrients in conditions such as intestinal resections, infections or malabsorption syndromes. Hormones of the so-called ileal brake (3-14) regulate appetite and intestinal motility to lower ingestion, delay gastric emptying, and regulate intestinal transit rates in settings where there is an imbalance between amount presented and amount absorbed. All of this is designed to recover food related nutrients that are reaching the ileum before the calories are removed. The release of ileal brake associated hormones regulates the efficiency of the intestines and the entire enteric nutrition pathway, and is capable of re-starting the absorption process as well as to reestablish homeostasis in settings where patients are overeating.(3-14)
Enteric hormones were described after gastric and intestinal resection and colonic transposition. In early experiments, the ileal and colonic mucosa was exposed to fresh food, triggering the release of the enteric peptides to very high levels (15, 16). In a human experiment in 1988, an oral tube was inserted through the mouth into the ileum and various nutrients were injected down the tube including fats and carbohydrates. The peptide was stimulated by the food that was deposited in the ileum bypassing the absorption (12). The description of what happened when normal people eat was summarized in John Walsh’s book on gut peptides (17, 18). Investigators found stimulation of those hormones starting 10 minutes after the mixed meal was ingested. These hormones, especially Glucagon-like peptide 1 (GLP-1) and enteroglucagon, peaked at 1-2 hours after oral food ingestion.
GLP-1, an insulinotropic hormone released from the intestinal L cells in response to nutrient ingestion, has been extensively reviewed with respect to beta-cell function. GLP-1 is both a gut-derived hormone and a neurotransmitter synthesized in the brain. Early reports suggested that GLP-1 acts in the periphery to promote insulin secretion and affect glucose homeostasis, whereas central GLP-1 reduces food intake and body weight. However, current research indicates that in fact, GLP-1 in each location plays a role in these functions. There is substantial evidence for involvement of peripheral and brain GLP-1 in food intake regulation and glucose homeostasis and proposes a model for the coordinated actions of GLP-1 at multiple sites.(19) However, GLP-1 receptors are abundant in many other tissues. Thus, the function of GLP-1 is not limited to the islet cells, and it has regulatory actions on many other organs. For example, it has been suggested that GLP-1 may have benefit in Congestive Heart Failure (20). GLP-1 has the ability to modulate myocardial glucose uptake and thereby make an impact on cardio protection. Glucose-insulin-potassium (GIK) infusions have been studied for decades, with conflicting results regarding benefit in acute myocardial infarction. Based on the same concepts, GLP-1 has recently been demonstrated to be a more effective alternative in left ventricular (LV) systolic dysfunction (20).
A review of published, peer-reviewed medical literature (1987 to September 2008) on the extra pancreatic actions of GLP-1 was performed (21). The extra pancreatic actions of GLP-1 include inhibition of gastric emptying and gastric acid secretion, thereby fulfilling the definition of GLP-1 as an enterogastrone. Other important extra pancreatic actions of GLP-1 include a regulatory role in hepatic glucose production, the inhibition of pancreatic exocrine secretion, cardio protective and cardio tropic effects, the regulation of appetite and satiety, and stimulation of afferent sensory nerves. The primary metabolite of GLP-1, GLP-1 (9-36) amide, or GLP-1m, is the truncated product of degradation by dipeptidyl peptidase-4. GLP-1m has insulinomimetic effects on hepatic glucose production and cardiac function. Exendin-4 present in the salivary gland of the reptile, Gila monster (Heloderma suspectum), is a high-affinity agonist for the mammalian GLP-1 receptor. It is resistant to degradation by dipeptidyl peptidase-4, and therefore has a prolonged half-life. In conclusion, GLP-1 and its metabolite have important extra pancreatic effects particularly with regard to the cardiovascular system and insulinomimetic effects with respect to glucose homeostasis. These effects may be particularly important in the obese state. (21).
By contrast, food-related stimulation of GLP-1 is hypo-responsive or even absent in obese patients. Marks et al. also showed a remarkable absence of GLP-1 response to oral glucose in obese patients (22), indicating a down-regulation of the ileal brake pathway in the pathogenesis of obesity. On the other hand, obese patients who undergo bariatric surgery lose weight gradually by suppression of appetite. They also experience very positive impact on glucose levels in the blood and improvement in insulin resistance. One possible explanation for all of these effects is an activation of the ileal brake pathway by bariatric surgery, just as would be expected from the experiments delivering high amounts of nutrition to the ileum via an enteric tube (23, 24).
In 1996 it was postulated that this stimulation happens via neurotransmission (25), and to some extent involves GIP indirectly via neuron-stimulation of the ileal brake hormones. The effect could be inhibited by lowering neuron stimulation using blockers. Others have challenged these findings, and alternatively proposed that the ileal brake effects are mediated directly by the L-Cells that are found throughout the intestinal tract. In fact they argue that the effect on L-Cells coexists with the GIP hormones in the upper jejunum and with PYY in the lower gut.
Fractionation experiments with enteroglucagon resulted in isolation of GLP-1 and GLP-2. Because of its insulin activity GLP-1 is used to treat diabetics, and was noted to have significant weight loss properties. Analogues to GLP-1 made available for treatment of diabetes such as Exenatide (Byetta) are associated with favorable glucose control and appetite suppression associated weight loss. Other hormones in the ileal brake pathway, such as PYY analogues, were also made available and trials were also designed to use these in the treatment of human obesity.
Holst and colleagues (2006) published a detailed review on the action of GLP-1 on different parts of the body to include the muscles, nervous system, the heart as well as the pancreas the liver intestine and brain (26). GLP-1 was shown to be a powerful regulator of food intake in humans at physiological levels (27, 28).
Recently Liraglutide, a GLP-1 analogue given parenterally, was shown in a double blind study to induce weight loss (29). Liraglutide was assessed in obese individuals without type 2 diabetes in a 20-week trial, with open-label Orlistat comparator in 19 sites in Europe. 564 individuals (18-65 years of age, body-mass index 30-40 kg/m2) were randomly assigned, to one of four Liraglutide doses (1.2 mg, 1.8 mg, 2.4 mg, or 3.0 mg, n=90-95) or to placebo (n=98) administered once a day subcutaneously, or Orlistat (120 mg, n=95) three times a day orally. All individuals had a 500 kcal per day energy-deficit diet and increased their physical activity throughout the trial, including the 2-week run-in.
Weight change analyzed by intention to treat was the primary endpoint. An 84-week open-label extension followed. Participants on Liraglutide lost significantly more weight than did those on placebo (p=0.003 for Liraglutide 1.2 mg and p<0.0001 for Liraglutide 1.8-3.0 mg) and Orlistat (p=0.003 for Liraglutide 2.4 mg and p<0.0001 for Liraglutide 3.0 mg). Mean weight loss with Liraglutide 1.2-3.0 mg was 4.8 kg, 5.5 kg, 6.3 kg, and 7.2 kg compared with 2.8 kg with placebo and 4.1 kg with Orlistat, and was 2.1 kg (95% CI 0.6-3.6) to 4.4 kg (2.9-6.0) greater than that with placebo. More individuals (76%, n=70) lost more than 5% weight with Liraglutide 3.0 mg that with placebo (30%, n=29) or Orlistat (44%, n=42). Liraglutide reduced blood pressure at all doses, and reduced the prevalence of prediabetes (84-96% reduction) with 1.8-3.0 mg per day. Nausea and vomiting occurred more often in individuals on Liraglutide than in those on placebo, but adverse events were mainly transient and rarely led to discontinuation of treatment. These findings have led to the postulated GLP-1 action in the brain to induce satiety, and suggested that it is a neurotrophic agent (30, 31).
GLP-2 targets growth and regeneration of the enteric organs, therefore acting as a growth factor hormone which serves in the recovery of the body from injury (32-37). PYY was shown to induce satiety as well as to suppress acid secretion combined with GLP-1, and act on motility significantly (38, 39). PYY was also tested by both injection and nasal administration, but was itself unsuccessful for prevention and treatment of obesity. Some studies suggest that stimulation of all the hormones of the ileum simultaneously worked synergistically to suppress appetite and regulate both glucose and insulin, and the result of this synergy was notable by its actions at lower doses and mainly on the portal system.
Project Description
Given that the most natural way to stimulate those hormones is the gut stimulation of the ileal brake pathways, we devised a project and a product to reset the ileal brake in patients. Our major goals were:
1. To establish proof of concept with oral activation of the ileal brake pathways, whereby an oral pill containing food content that is protected with an enteric-coating mechanism, could deliver this food content to the distal ileum, and thereby stimulate ileal brake hormones.
2. To demonstrate that stimulation of the ileal brake with this formulation is reproducible and can cause the released ileal hormones to reach significant levels physiologically in humans.
3. To determine a time related pattern of response to stimulation of the ileal brake and to use the local enteric stimulation as means of re-setting the ileal brake of obese patients.
4. To demonstrate stimulation of the ileal brake in overweight and obese patients.
5. To demonstrate that the increase in the hormones of the ileal brake cause weight loss in obese patients by regulating gut-brain satiety signals and therefore appetite.
6. To study the interactions between ileal brake hormones and systemic effects, such as control of blood sugar, insulin homeostasis, and appetite control.
7. To establish doses, administration times and optimal schedules for APHOELINE 1 in treated patients with obesity.
This project was designed to reset a biological process regulating satiety and appetite. It tests an endogenous pathway that appears to be hypo-responsive in obese patients. It is believed that a reset of the so called ileal break mimics the effect of bariatric surgery in the obese patient, without exposing the obese patients to the risks of surgery. If successful, the product will use an existing pathway, associated controls and feedback loops, avoiding complications and side effects. We will help the body regain control of the intestinal factors that regulate ingested nutrients and weight. Furthermore, giving patients control of an unconscious part of satiety, a pathway that is very difficult to deal with at the conscious level, will make it easier for them to follow a diet and lose weight. There is no evidence that the hypo-responsive ileal brake in obese patients is an organic defect that cannot be subject to external regulation, although it is theoretically possible since some patients do not respond to bariatric surgery.
Methodology:
As a starting point we needed to calculate the amount of food needed to deliver to the ileum. For that purpose we decided to use carbohydrate as a starting solution. Carbohydrate is a significant stimulus to the ileal brake mechanism (12), and it was easy to monitor for any absorption or failure of the pill by checking the blood sugar level. Finally, absorption of carbohydrate stops much sooner than fat and gives us more room for the initial testing of the pill.
Based on the above we have to calculate the right amount of calories to be delivered to the ileum. We decided to proceed with testing the minimal amount of carbohydrate needed to stimulate insulin and be visible in the blood stream; we termed this a minimal metabolic unit. The thought behind it was that if the upper gut was able to perceive it as food, the lower gut that is supposed to monitor malabsorption should be able to react to it as a signal of malabsorption. It was determined that the unit should be between 8 to 15 gm of carbohydrate. The amount used by ‘Dr Bloom in his direct ileal stimulation experiments was around 15 gm (12).
The second task was to have the coating for the pill to deliver the carbohydrate to the ileum without proximal small bowel absorption. This required a slow release formulation to avoid an osmotic side effect.
Because of the amount of carbohydrate involved in re-setting the ileal brake, the goal was to decrease the number of the pills, starting at 18 and decreasing the number to a manageable level of 7 per day. The formulation and dose finding experiments started in 2003, and by 2008 we had arrived at 4-5 different formulations that withstood these in-vitro challenges and were ready for testing.
Three trials were conducted with pilot formulations to arrive at the components of APHOELINE 1 After informed consent from healthy volunteers, monitored at all times medically the pills were given after an overnight fasting state and blood work was drawn on an hourly basis for 10 to 12 hours testing. Measured were the peptide ileal brake associated hormones and their associated biomarkers: blood sugar, insulin, c-peptide, and in the last tests IGF-1, IGF-2. Patients were allowed to drink water ad libitum. The samples were drawn according to the recommendations of the various specialized labs by professional registered nurses, and the blood was handled on the premises by a reference lab (which one) immediately on withdrawal, each tube coded accordingly packaged on dry ice and shipped overnight to the specialty labs.
Patients were separated in different groups. The groups were handled sequentially. Each subject in the group was handled simultaneously with the other elements of his group at a separate drawing station with a registered nurse, according to the time schedule. Therefore group 1 was done all at one time at the different stations from one to seven, the time frame was kept by an independent monitor to try to assure punctuality.
Initially the groups were processed and paper were filled out with a short history and physical , consent were signed, and a heparin lock was placed by the nurse at the station , then a draw at zero time was done , time was marked then the pills was given to all individual of group at the same time. The same was done to the other groups sequentially. Blood was drawn thereafter as per protocol on an hourly basis on the clock for all members of the group simultaneously, at every draw the person and vitals were assessed and blood drawn from the heparin lock, after saline flush and after discarding the first cc s to avoid high heparin concentration. For testing the GLP-1, GLP-2, and PYY was as follows: EDTA (purple top) tubes with addition of 500 micro liters of Aprotinin and 10 micro liters of DPP IV per tube. Collect blood, centrifuge within 10 minutes in a 4 degree C centrifuge. Pour off supernatant (plasma) and immediately freeze. 2.5 ml plasma to a container or combine two plasmas from the same subject at "same time point" into a 6 ml container. Labeled and code each tube separately according to a pre organized labeling system. The tubes were Stored and ship these specimens at -70C. The Insulin, C-peptide and glucose were collected in SST tubes, spun and sent to the local national lab.
Results were reported from the reference lab and decoded back in standard excel format, and forwarded to us for analysis.
The results were studied by statistical analysis: the results are as follows:
Heparin lock, after saline flush and after discarding the first cc s to avoid high heparin concentration. The blood was placed in 2 separate tubes from the same draw to assure redundancy and control, in Vacutainer tubes containing protease inhibitors (EDTA, Aprotinin, and DPP IV inhibitor) cocktails. After blood collection and centrifuged in refrigerated centrifuge, in those tubes, then transfer the 2.5 ml plasma to a container or combine two plasmas from
the same subject at "same time point" into a 6 ml container. To freeze, labeled and code each tube separately according to a pre organized labeling system then ship in dry ice as soon as possible to the peptide labs measurement preferably over night.
The hormone data set was statistically analyzed; the results are described in the next section.
Results of Statistical Analyses
APHOELINE 1 has been developed after testing a sequence of formulations and careful statistical analyses of the blood test results. Testing was done at three different times with three different formulations, as shown in Table 1:
Table 1: Time of testing and formulation
|
Time |
Formulation |
SUBJECTS* |
|
August 2008 |
Aphoeline 1 1 -2 |
A, F, G, H, I, J, K, P, U |
|
September 2008 |
Aphoeline 1 1 -1 |
E, K, N |
|
October 26, 2008 |
Aphoeline 1 1-0 |
A, B, C, D, E |
|
October 26, 2008 |
Aphoeline 1 1 |
F, G, H, I, J |
*There were different subjects at different testing times [e.g., Subject A in August testing is not same as Subject A in October testing]
Results of Statistical Analysis: 10-26-2008 Data
The R software package for statistical computing was used for all statistical analyses and data visualization.
1) Measurements of GLP1, GLP2, and IGF-I, IGF-II, Glucose, Insulin, C-Peptide and pyy for each of the 10 subjects were plotted against time (Figures 1, 2, 3, and 4).
2) It can be seen from Figure 3 that [i] all 5 APHOELINE 1 subjects [F, G, H, I, J] have elevated Glucose levels at time 0, [ii] except for subject G, the Glucose level monotonically decreases to normal levels; in the case of Subject G, Glucose level starts at 113, goes down to 98, goes up to 112 and then goes down to 108.
3) It is also apparent from Figure 3 that two of the subjects [G and I] in the APHOELINE 1 1 Group had slightly elevated insulin levels at time 0; in both of these cases, the insulin levels decreased by time 10.
4) Figure 5 shows the average concentrations of GLP1, GLP2, IGF-I, IGF-II, Glucose, Insulin, C-Peptide and pyy plotted against time of measurement for the Aphoeline 1 1-0 Group (concentrations at each time averaged over the subjects A – E), and Figure 6 shows these averages for the Aphoeline 1 Group (concentrations at each time averaged over the subjects F – J). We can see from Figures 5 and 5 that he average concentrations of Glucose and insulin decrease with time.
5) Mann – Kendall nonparametric test for trend was used to determine if both insulin and glucose levels decrease over time for Aphoeline 1 -0 and Aphoeline 1 Groups. These results are shown in Table 2.
Figure 1: October 28, 2008 Testing Results for GLP1 and GLP2 by Formulation
Aphoeline 1 -0 and Aphoeline 1 )
Figure 2: October 28, 2008 Testing Results for IGFI and IGFII by Formulation (Aphoeline 1 -0 and Aphoeline 1) .
Figure 3: October 28, 2008 Testing Results for Glucose and Insulin by Formulation (Aphoeline 1 -0 and Aphoeline 1)
Figure 4: October 28, 2008 Testing Results for C-Peptide and pyy by Formulation (Aphoeline 1 -0 and Aphoeline1)
Figure 5: Average Hormone Levels for Aphoeline 1 -0 Group 
Figure 6: Average hormone levels for Aphoeline 1 1 Group
|
Table 2: Results of Mann – Kendall nonparametric test for trend Product |
Subject |
Mann - Kendall Statistic for Glucose |
P – value for the alternative hypothesis of decreasing trend |
Mann - Kendall |
P – value for |
|
Aphoeline 1 1-0 |
A |
-.5 |
.02* |
-.299 |
.12 |
|
Aphoeline 1 1-0 |
B |
-.64 |
.005* |
-.441 |
.055** |
|
Aphoeline 1 1-0 |
B |
-.524 |
.015* |
-.554 |
.015* |
|
Aphoeline 1 1-0 |
D |
.82 |
.0003* |
.04 |
.94 |
|
Aphoeline 1 1-0 |
E |
-.496 |
.025* |
-.93 |
.00005* |
|
Aphoeline 1 1 |
F |
-.774 |
.0007* |
.0556 |
.44 |
|
Aphoeline 1 1 |
G |
-.112 |
.35 |
-.33 |
.09** |
|
Aphoeline 1 1 |
H |
-.389 |
.06** |
.11 |
.35 |
|
Aphoeline 1 1 |
I |
-.624 |
.005* |
-.352 |
.08** |
|
Aphoeline 1 1 |
J |
-.61 |
.007* |
--- |
--- |
|
Table 3: Results of Mann – Kendall nonparametric test for trend Product Product |
Subject Subject |
Mann – Kendall Statistic for |
|||||||||
|
Glucose |
C-Peptide |
Insulin |
|||||||||
|
|
P – value |
|
P – value |
|
P – value |
||||||
|
Aphoeline 1 1-0 |
A |
-.66 |
.003* |
-.673 |
.003* |
-.636 |
.004* |
||||
|
Aphoeline 1 1-0 |
F |
-.86 |
.0002* |
-.722 |
.002* |
-.807 |
.0004* |
||||
|
Aphoeline 1 1-0 |
G |
-.697 |
.002* |
-.66 |
.003* |
-.236 |
.35 |
||||
|
Aphoeline 1 1-0 |
H |
-.648 |
.004* |
-.74 |
.002* |
-.6 |
.006* |
||||
|
Aphoeline 1 1-0 |
I |
-.611 |
.006* |
-.785 |
.0006* |
-.455 |
.03* |
||||
|
Aphoeline 1 1 |
J |
-.623 |
.005* |
-.648 |
.004* |
-.309 |
.10** |
||||
|
Aphoeline 1 1 |
K |
-.597 |
.01 |
-.472 |
.03 |
-.236 |
.17 |
||||
|
Aphoeline 1 1 |
P |
-.908 |
.0001* |
-.785 |
.0006* |
-.382 |
.06** |
||||
|
Aphoeline 1 1 |
U |
-.572 |
.01* |
-.86 |
.0002* |
-.855 |
.0002* |
||||
|
Aphoeline 1 1 |
E |
-.785 |
.006* |
-.927 |
.00002* |
-.527 |
.015* |
||||
|
Aphoeline 1 1 |
K |
-.917 |
.00006* |
-.85 |
.0003* |
-.341 |
.10** |
||||
|
Aphoeline 1 1 |
N |
-.774 |
.0007* |
-.88 |
.0001* |
-.782 |
.0005* |
||||
|
Aphoeline 1 1 |
F |
-.774 |
.0007* |
-.812 |
.0005* |
.06 |
.88 |
||||
|
Aphoeline 1 1 |
G |
-.112 |
.35 |
-.587 |
.007* |
-.33 |
.09** |
||||
* Downward trend significant at test size 0.05, * *downward trend significant at test size 0.1
Results for Subjects with Elevated Glucose and/or Insulin Levels
Figures 13 – 26 show the levels of Glucose, C-Peptide and Insulin plotted against time for a subset of the data set generated during August – December 2008 testing, for which initial Glucose and/or Insulin levels are elevated. It can be seen from these figures that the levels of Glucose, C-Peptide and Insulin all return to normal for subjects taking any of the three Aphoeline 1 formulations [Aphoeline 1 -2, Aphoeline 1 -2, and Aphoeline 1 1].
7: Glucose concentrations for subjects with elevated Glucose/Insulin concentrations
Figure 8: C-Peptide concentrations for subjects with elevated Glucose/Insulin concentrations
figure 9: Insulin concentrations for subjects with elevated Glucose/Insulin concentrations
Weight Loss Associated with Positive Side Effects
Figure 10 shows the total weight loss observed for a subject on Aphoeline 1 1 (50 year old female) as a function of days between measurements, and Figure 11 shows levels of liver enzymes in the same patient at the times of measurements. For this subject, Aphoeline 1 1 clearly has a positive and significant effect on liver enzymes.
Figure 10: Total weight loss for a 50 yowf with an initial blood sugar fasting of 220, ending with a blood sugar fasting of 110 .
Figure 11: Levels of liver enzymes for a steatohepatitis patient
Discussion
Injection of analogue of GLP-1 peripherally is a familiar approach in the treatment of diabetes, and produces appetite suppression in a manner similar to Aphoeline 1 1 treatment. However, the properties of peripheral GLP-1 include a different distribution pattern and a short half life of approximately 3 minutes. The majority of the dose does not enter the portal system as it would if GLP-1 was induced by GI tract stimulation and with peripheral administration less than 15 % will go through the liver to the periphery. While exogenous use of enteric ileal brake hormones is demonstrated to have an effect on appetite suppression, the idea of resetting the endogenous ileal brake in the lumen of the GI tract has not been tried before, other than by bariatric surgery. The ileal brake pathway is optimally activated LOCALLY in the distal small bowel, and when stimulated properly these ileal brake hormones act synergistically and in a highly complementary manner, which both avoids side effects associated with only one of them administered parenterally. The drawback to the peripheral injection approach of GLP-1, although proven to have appetite suppression, is partly a delivery site problem. For example, subcutaneous injection of GLP-1 mimetic, at supra-physiological levels, does not allow the advantages of portal application of lowered amounts. Thus the liver and pancreas effects are not beneficial; only the brain appetite suppression axis is activated. Furthermore there are GLP-1 receptors in non-target organs like the heart and kidney, and these may explain some of the recently noted side effects of Exenatide. Thus the portal system is where most of the action is taking place, and activation of the local ileal brake pathways lead to the full complement of benefits beyond appetite suppression. With oral administration of Aphoeline 1 1, there is appetite suppression, but also beneficial effects on glucose control, insulin pathways, re-set pancreatic glucose sensors, hepatic glycogen storage and glucose release, and mobilization of adipose tissue.
The actions controlled by Aphoeline 1 1 are in the GI tract itself all the way from the esophagus to the rectum. Another problem with peripheral GLP-1 is the development of antibodies to the peptide within one year and up to 40% of the treated patients with Exenatide. The other side effects of Exenatide include pancreatitis and renal failure associated with the treatment.
On reviewing the literature in regard to appetite control and obesity the mainstream approach has been caloric counting and exercise. Excessive caloric intake has been linked to a psychological problem. As a consequence, from the patient viewpoint they are either addicted to food without will power or the patient is not sufficiently active to compensate for the intake of calories (49). Though valid, these statements do not give an accurate picture of the problem afflicting the large proportion of patients that appear to be very balanced psychologically and despite their best efforts are not capable of losing weight. Some reviews suggest that people under stress tend to lose less weight than people under less stressful situations, ascribing cortisol as the etiological factor. Other studies using a rat model (48) suggest that obesity is predetermined and one will tend to go back to the genetic curve with age.
We do know that certain conditions, including diabetes, hypertension, insulin resistance, commonly used antidepressants and anti-psychotics are associated with weight gain. The effect of bariatric surgery on patients with obesity and concomitant diabetes also seem to be mediated thru the suppression of appetite centrally after local GI activation of the ileal brake pathway. The mechanism of action is not psychological as oral caloric intake and energy expenditure, since patients with a bypass surgery for obesity have improved appetite control compared to people that undergo a lap band surgery. The effectiveness of bariatric surgery is also related to the connection site of the bypass. Make it too short and severe malabsorption results, while if the loop is too long the patient does not lose weight. Another consistent observation is the favorable weight loss action of LIRAGLUTIDE in spite of no major changes in patient behavior or lifestyle (29).
The other approach to the treatment of obesity is to try to bypass different systems like providing medications that work directly on the satiety center by different medications that are available on the market. The different side effects that will have to be dealt with include hypertension, stroke, addiction, seizures, cardiac arrhythmias and coronary events, pulmonary hypertension, severe depression, suicide, and insomnia. Even when the patient looses weight, there is a rebound off medications associated with binge eating and the patient ends up being either recycled in the system for another course of therapy in weight control centers, or gaining more weight than he started with, putting him at risk that could be higher than the baseline due to the severe weight fluctuations over short periods of time.
Vildagliptin is a selective dipeptidyl peptidase IV inhibitor that augments meal-stimulated levels of biologically active glucagon-like peptide-1. Chronic Vildagliptin treatment decreases postprandial glucose levels and reduces hemoglobin A1C in type 2 diabetic patients. However, little is known about the mechanism(s) by which Vildagliptin promotes reduction in plasma glucose concentration. METHODS: Sixteen patients with type 2 diabetes (age, 48+/-3 yr; body mass index, 34.4+/-1.7 kg/m2; hemoglobin A1c, 9.0+/-0.3%) participated in a randomized, double-blind, placebo-controlled trial. On separate days patients received 100 mg Vildagliptin or placebo at 1730 h followed 30 min later by a meal tolerance test (MTT) performed with double tracer technique (3-(3)H-glucose iv and 1-(14)C-glucose orally). RESULTS: After Vildagliptin, suppression of endogenous glucose production (EGP) during 6-h MTT was greater than with placebo (1.02+/-0.06 vs. 0.74+/-0.06 mg.kg-1.min-1; P=0.004), and insulin secretion rate increased by 21% (P=0.003) despite significant reduction in mean plasma glucose (213+/-4 vs. 230+/-4 mg/dl; P=0.006). Consequently, insulin secretion rate (area under the curve) divided by plasma glucose (area under the curve) increased by 29% (P=0.01). Suppression of plasma glucagon during MTT was 5-fold greater with Vildagliptin (P<0.02). The decline in EGP was positively correlated (r=0.55; P<0.03) with the decrease in fasting plasma glucose (change=-14 mg/dl). CONCLUSIONS: During MTT, Vildagliptin augments insulin secretion and inhibits glucagon release, leading to enhanced suppression of EGP. During the postprandial period, a single dose of Vildagliptin reduced plasma glucose levels by enhancing suppression of EGP.(40)
Other approaches to weight loss target absorption, create states of malabsorption, produce stool incontinence, and may result in fatty liver and other undesirable effects (51).
Based on these premises leaders in the field started to emphasize a more natural GI tract based approach to weight loss that would involve all the endogenous mechanisms that regulate caloric intake and body weight. The goal was to lose more weight with fewer side effects, and the standard is Bariatric Surgery. A recent review of approaches to this problem eloquently summarizes the field (17, 41-44). The focus is shifting to the ileal brake pathways that are using the body natural signals: the gut hormones for future research of obesity pharmacotherapy (45, 46).
Based on our clinical observations, there is a component of hunger and obesity that is visceral and unconscious. To a certain extent, these effects are unknown to the patient, making it very difficult for the person to control appetite. The person at the time will be trying to replace the lack of visceral perception with an alternative voluntary conscious awareness resulting in continuous monitoring of the calories and input output as well as calories used and activity at all time to control the weight. This is difficult, and often causes frustration to those attempting to lose weight in this manner.
Low-glycemic index (GI) foods and foods rich in whole grain are associated with reduced risk of type 2 diabetes and cardiovascular disease. Nilsson and Holst examined the effect of cereal-based bread evening meals (50 g available starch) that varied in content of indigestible carbohydrates, on glucose tolerance and related variables after a subsequent standardized breakfast in healthy subjects (n = 15). At breakfast, blood was sampled for 3 h for analysis of blood glucose, serum insulin, serum FFA, serum triacylglycerides, plasma glucagon, plasma gastric-inhibitory peptide, plasma glucagon-like peptide-1 (GLP-1), serum interleukin (IL)-6, serum IL-8, and plasma adiponectin. Satiety was subjectively rated after breakfast and the gastric emptying rate (GER) was determined using paracetamol as a marker. Breath hydrogen was measured as an indicator of colonic fermentation. Evening meals with barley kernel based bread (ordinary, high-amylose- or beta-glucan-rich genotypes) or an evening meal with white wheat flour bread (WWB) enriched with a mixture of barley fiber and resistant starch improved glucose tolerance at the subsequent breakfast compared with unsupplemented WWB (P < 0.05). At breakfast, the glucose response was inversely correlated with colonic fermentation (r = -0.25; P < 0.05) and GLP-1 (r = -0.26; P < 0.05) and positively correlated with FFA (r = 0.37; P < 0.001). IL-6 was lower (P < 0.01) and adiponectin was higher (P < 0.05) at breakfast following an evening meal with barley-kernel bread compared with WWB. Breath hydrogen correlated positively with satiety (r = 0.27; P < 0.01) and inversely with GER (r = -0.23; P < 0.05). The authors concluded from these experiments that composition of indigestible carbohydrates of the evening meal may affect glycemic excursions and related metabolic risk variables at breakfast through a mechanism involving colonic fermentation. The results provide evidence for a link between gut microbial metabolism and key factors associated with insulin resistance.(47)
Going back to the literature trying to figure out the different responses of the body to food between normal and overweight or obese patients, the only significant abnormality that was reported, is the response of the ileal break to the intake of the mixed meal (17, 22), and more specific to carbohydrates. Therefore it seems the natural satiety pathways become tolerant to the intake of carbohydrates. This partially explains the success of the Adkins diet, even though in this case there are no demonstrable differences in the anatomy or histology of those two groups, except in rare cases of severe morbid long term obesity associated with atrophy of the ileum. Given the fact that food delivered to that part of the intestine is capable of stimulating those hormones independently of oral intake and the fact that the ileal stimulation during a mixed meal can be inhibited by suppressing the neurotransmission raise the possibility that the problem seems to be about the transmission of the signal from gut to brain. It is possible that a reset of a carbohydrate tolerant ileal brake pathway will re-set the appetite center and renew the feedback loop that interrupts eating, all without progression to a metabolic syndrome. Therefore if we are able to directly stimulate the ileum we should be able to restore the ileal brake signal and at least give the patient some help in restoring visceral signals that measures the food intake.
These visceral signals are not only important to signal satiety but as per reported reviews (34, 44) these hormones are extremely beneficial to the patient. Their absence during down-regulation could be what the patient's are seeking unconsciously when they overeat, energy improve muscle, liver, intestine stomach, nerve and heart. Since these hormones are also very important in the homeostasis of the insulin and glucose levels they will help tremendously in the use is of the reserves that are already present.
By stimulating the hormones naturally with Aphoeline 1 1 we are delivering the majority of the hormones where they belong in the portal system, where they have the most powerful impact on satiety. We were also encouraged by the fact that the bypass surgery for obesity is capable of stimulating those hormones in all patients, indicating that the innate ability of these hormones to respond is still present.
We set a goal to stimulate the ileal hormones with an oral natural agent consistent of a nutritional substance. The data are compelling and the stimulation of the ileal brake pathway seems independent of age or weight or diabetes. This establishes the intestine still functions despite obesity, and the problem seems to be in the down-regulation of the signaling from the ileum. (Another confirmation to that statement comes from the surgical bypass that in appropriate individual triggers the same process).
What we discovered from these stimulation that it have a very powerful effect on the glucose and insulin homeostasis not consistent with the assumption that these peptides work only by stimulation of the insulin but mainly through reducing insulin resistance as well long before they achieve weight loss. This is also consistent with the data from bypass surgery.
The more powerful effect on steato- hepatitis seen by decrease of the enzymes level to normal within 3-4 weeks need to be studied on a much longer duration to confirm the trend and the gains, but it seems from the energy, satiety and the trend to normalize triglyceride and cholesterol as well as to the satiety factors and surprising improvement of all parameters including platelets that the trend is true. Similar platelets trend is seen in cirrhotic patients (non-published data).
Based on the recent publication of Lirutaglide and weight loss(29), the GLP-1 family of gut hormones will induce weight loss but in a different way than expected, the weight loss is slow and happens after other parameters start to improve. Weight loss is insidious, just like weight gain, and occurs on a rather unconscious level. The pathway is re-activated after being dormant and the distal caloric signals are now once again responded to in the ileum.
The advantage of having an oral stimulation of all the ileal hormones is the synergistic effect of the hormones that were meant to be stimulated together in a broad pathway beyond any individual component. The fact that these hormones are released in the portal system that seems to be the center of all metabolism except the muscles and the brain, the fact that the highest concentration of these hormones is in the portal system make our stimulation much less intrusive and more efficient than the peripheral administration of such hormones.
The suppression of insulin resistance need further investigation even though we showed that the IGF system is stimulated, we do not feel this is the only answer to the question; other peptides as well as other cellular receptors such as the RR receptors need to be investigated as part of the equation. In the next section, we prioritize our future work in this direction.
The stimulation of the ileal hormones with Aphoeline 1 1: present opportunities and challenges.
1. A continuing priority is to improve the ileal brake stimulation potency with further adjustments of the formulation content and the ileal delivery system.
2. Another priority is to develop more practical tests to document the anticipated down-regulation of the ileal brake pathway in the obese, and to demonstrate the impact of Aphoeline 1 1 in the resetting of this pathway. This testing should be applied to study of a variety of GI diseases such as irritable bowel, and to examine the relationships between hormones and intestinal permeability, immune system and bacterial flora.
3. Third priority is to check on the long term effects of the oral stimulation on improving muscles, pancreas, suppression of acid of the stomach as reported, and determine if the epidemic of reflux and adenocarcinoma increase could be explained on the basis of these hormones deficiency or abnormal responses .as reported PYY and GLP1 inhibit together gastric acid secretion 100%.
4. It is necessary to examine the effects of Aphoeline 1 1 on GI motility including the esophagus and achalasia since these hormones were reported to be neurotrophic. The effect on the lung has not been studied yet, but since it improves the function of other muscles it should have a beneficial impact on the costal muscles, as well as those of the bronchi and the diaphragm.
5. Diabetes is a major target and its innocuous profile should be considered as a first line of treatment, large study and long term effect should be targeted including HbA1c, all indications that the ileal brake pathway does improve diabetes. Because of its effect on insulin resistance, other circumstances of insulin resistance should be checked as well including but not limited to polycystic ovaries.
6. We also would study the effect on the liver. Even though it helps fatty liver it seems that it effect should be checked in different conditions as well including different hepatitis as a co-adjuvant therapy.
7. We would also investigate the use of Aphoeline 1 1 as a co-adjuvant therapy in bypass surgery. Assessment of action prior to surgery to study the ileal response or to stabilize the patient and improve their gut or post op as a salvage therapy, or co-adjuvant, should be considered.
The to-do list and the excitement are limitless, especially considering that these effects were produced by a benign orally administered natural product. Reactivation of a dormant gut peptide mechanism is a means of examining the gut as well as obesity from a new perspective.
Summary:
We have demonstrated the feasibility of a benign food substance delivered orally to stimulate the ileal hormones. The response appears to be sufficient to standardize the stimulation of the ileal brake hormones. Some unusual effects of that stimulation included suppression of insulin resistance, improvement in blood glucose levels, and significant early improvement in liver enzymes and lipid levels. While these beneficial effects were sustained in short term experiments, further large scale clinical testing and longer term clinical studies will be needed to confirm the persistence of these effects.
Based on our open trials, the long term effect of the Aphoeline 1 1 formulation is an increase in energy levels. There was an unconscious awareness of the calorie intake and a resetting of appetite which then resulted in significant weight loss. Long term double-blind placebo controlled trials, similar to the one conducted with Liraglutide, are being planned.
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