EDUCATION/TRAINING INSTITUTION AND LOCATION: Phillips Academy Andover; Saint Andrew s School

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1 NAME: Fukumori, Riku; Martinez, Ricardo POSITION TITLE: Principal Investigator EDUCATION/TRAINING INSTITUTION AND LOCATION: Phillips Academy Andover; Saint Andrew s School FIELD OF STUDY: Pharmacology PERSONAL STATEMENT (RIKU): I currently attend Phillips Academy Andover and I am entering my fourth year as a Senior this fall of I took and completed a Junior Biology course in my freshman year and I hope to pursue medicine in college. Besides Biology, I completed Advanced College Chemistry in my Sophomore year and AP Physics my Junior year. PERSONAL STATEMENT (RICO): I currently attend Saint Andrew s School and I am entering my fourth year as a Senior this fall in I have taken honors physics and honors chemistry my freshman and sophomore year and am presently enrolled in the International Baccalaureate Diploma Program, taking a 2 year long Higher Level Biology class. I anticipate pursuing medicine in college and graduate school.

2 Title of Project: The effects of intravenously injected ghrelin on the hunger levels and food intake with patients diagnosed with AN (anorexia nervosa). Hypothesis Intake of ghrelin over a one month period will increase hunger sensation and food intake in various patients with appetite loss, and will aid the healing process of psychological stress induced anorexia, without any adverse side effects. Specific Aim 1 Examine and determine the exact mechanism of ghrelin that induces hunger in patients with and without appetite loss and AN. Background Ghrelin is a chemical primarily secreted by the stomach during hunger and starvation and it stimulates hunger sensations and growth hormone (GH). [1] Ghrelin and its receptors are primarily involved in the regulation of food intake, obesity, and GH secretion. [2] Ghrelin works hand and hand with leptin, which primarily inhibits hunger sensations. Intravenous infusion of ghrelin is reported to increase food intake and body weight, and stimulate appetite in healthy subjects. In addition, patients with congestive heart failure cancer, and many other conditions also yielded similar results. [3] Anorexia nervosa (AN) usually begins with psychological stress induced anorexia and is characterized by an extreme fear of weight gain, abnormal behaviors caused by hunger, and many issues due to malnutrition. Chronic malnutrition induces both negative functional and organic changes in the gastrointestinal tract. [4] Most AN patients complain of chronic or recurrent upper abdominal discomfort and fullness, and chronic constipation. Currently prescribed appetite stimulating drugs such as metoclopramide, cyproheptadine, and sulpiride are not always effective, and any increase in appetite are barely noticeable. [5] To develop a possibly new medical treatment for AN, we will investigate the effects of ghrelin on appetite, energy intake, and nutritional parameters in AN patients without binge eating/purging as a study. A factor that must be taken into consideration is the psychological aspect of AN. Most patients suffer from various mental conditions that physically prevent them from ingesting food. However, this investigation will focus on patients who have recovered from the mental aspect and suffer from a physical loss of appetite. Intravenous intake of ghrelin is anticipated to gradually increase the appetites of patients affected with AN and not cause adverse side effects such as dependency or fluctuations in normal endocrine secretions.

3 RESEARCH STRATEGY Significance Significance to Human Health: Approximately 11 million Americans suffer from an eating disorder, and AN is the third most common chronic illness amongst adolescents. [6] Research has been conducted in the past with ghrelin on AN patients, however the experiments did not include blind, placebo controlled groups. This investigation will include randomized, placebo controlled groups in a double blind setting, wherein both subjects and providers will not be notified of whether they are the control group or not. Ethical complications can be avoided due to the previously successfully conducted experiments with intravenously injected ghrelin as well as the gradual increase of the amount of ghrelin over the one month period. Significance to increasing our understanding of AN and the effectiveness of injections of endogenous chemicals: This study will improve the overall understanding of AN and will further improve conventional methods of treatment and/or potentially cure. This study may potentially produce a solution that can be incorporated in the pharmaceutical industry and other medical practices. If a drug is developed from this study, it may be integrated into the private sector and sold to pharmaceutical companies. The most likely outcome to the study will be advancements in our general understanding of this hormone and its application as a treatment. Approach Chemical: Human ghrelin will be prepared as previously done. Acylated peptide will be dissolved in 3.75% D mannitol to yield a final concentration of 180 µg/ ml. The solutions will be filtered and stored at 20ºC in sterile vials. [7] Process: Subjects will be hospitalized for 36 days (day 6 to day 30) in the University of Florida Hospital. Food intake and subjective hunger sensation will be measured for the whole 36 days. A pretreatment period will be held in order to create a baseline for comparison and will be defined as the 5 days before ghrelin injection (day 5 to day 1). Subjects will receive varying amounts of intravenous infusion of ghrelin for 5 min twice a day (before breakfast and dinner) for 20 days (day 1 to day 20). These figures will be based on previous successful research and discussed later. [8] For the next 5 days (day 21 to day 25), all subjects will be infused with ghrelin at amounts of 1 µg/kg body weight as a buffer period. The last 5 days (day 26 to day 30) will be considered the post treatment period and subjects will not be infused with ghrelin, instead will be carefully monitored for the safety and efficacy of ghrelin. After the 36 day hospitalization, subjects will be released but will be monitored for the next 207 days. There will be a bi weekly check for vitals, physical examination, and a monthly questionnaire to again ensure the safety and efficacy of ghrelin. Subjects who decide that they

4 do not wish to participate at any point in this 8 month process will be immediately released with the necessary medication and all data tied with this subject will be erased. In addition, this experiment will be strictly double blind and placebo controlled, so neither subjects nor testers will be notified of the chemical nor type of experiment being conducted. In order to keep the integrity of blindness, the VAS questionnaires will not only contain queries obtaining to hunger and food intake, but also other random question such as CV health and stamina. 10% of each subject group will be randomly selected to be placebo controls and the other 90% will be injected with subsequently more ghrelin. For example, a certain subject group, take anorexic Middle Eastern women with familial history will look like this. Amount of ghrelin per kg body weight Placebo (0µg/kg) 1µg/kg 2µg/kg 3µg/kg 4µg/kg 5µg/kg 6µg/kg Number of subjects TOTAL: 100 Each subject group will have a total of 100 subjects, and each will have the same distribution of ghrelin injection. Data Collection: The primary endpoint of this study will be energy intake. Patients will be initially served with an amount of food equivalent to their meals at home before hospitalization. Each dish will be weighed before and after eating, and energy intake will be calculated by dieticians as total energy, carbohydrate, fat, and protein intakes. If subjects want more food than provided for, they will be allowed to eat their fill and the extraneous food provided will also be meticulously weighed and its energy intakes calculated. Meanwhile, the subject s attitudes toward food will be evaluated using a VAS (visual analogue scale) rating hunger, satisfaction, desire for particular food types (salty, fatty, sweet, etc.), and happiness. Subjects will answer extensive VAS questionnaires before and after the testing period, as well as a shorter, more concise VAS. During treatment, patients will take the VAS questionnaires 15 minutes before and after meals. It has been demonstrated that VAS questionnaires accurately correlate and represent hunger levels and fullness with food intakes. [9] Measures will be taken to ensure that adverse events do not occur during ghrelin treatment. At the end of each day, each patient will be checked for their vitals and physical evaluations, along with a weekly conversation with a certified psychologist on the subject s mental health and overall well being. Subjects will be carefully monitored tests will be terminated immediately upon any sign of adverse side effects. After the one month period of testing, subjects will be monitored weekly for vitals, physical evaluations, and blood tests to ensure that patients are independent from ghrelin injections to avoid substance dependency.

5 Potential Risks: AN, as previously discussed can be heavily influenced by psychological aspects and subject must be carefully selected so the ghrelin can have it s desired effect on patients that have to an extent recovered from the mental issues and are struggling with physically ingesting food. There may also be a high risk of adverse side effects on subjects with psychological problems. To combat this, patients must go through meticulous screening and ensure that their mental health is stable enough to go through testing. The human body regulates ghrelin according body weight. Ghrelin level increase as after dieting and decrease when one is overweight. We suspect that the body is making an attempt to stay at a certain body fat percentage through positive feedback. Prader Willi syndrome is a genetic disease in which the body is unable to regulate or limit ghrelin levels and obese patients dangerously increase in size. We fear that interference with ghrelin levels in the subjects will create a negative feedback response, creating a new normal. If the patient is overweight at the start of the study, the additional ghrelin injections may cause the body to alter its natural hormonal secretions. A post ghrelin treatment may be developed to counteract any permanent effects of the study. The hormone leptin may be needed to decrease hunger levels. Additionally, we fear that this study will create an imbalance in the natural endocrine system leading to dependency of artificial intravenous processes and spikes in complementary hormones. In this case, the complementary hormone for ghrelin is leptin, a hunger inhibiting hormone. If subjects become dependent on artificial hormonal injections, effects of the study may be dangerous and counteract the results we are looking for. Symptoms may include: malnutrition, anorexia, loss of energy, constipation, dependency of artificial injections, obesity, excessive eating, type 2 diabetes, coronary artery disease, high blood pressure, sleep apnea, depression, and death. However, the controlled experiment and the frequent VAS questionnaires along with the physical examinations will look to prevent these side effects from taking place. References [1] Kojima M, Hosoda H, Date Y, Nakazato M, Matsuo H, Kangawa K. Ghrelin is a growth hormone releasing acylated peptide from stomach. Nature. 1999;402(6762): [2] Shuto Y, Shibasaki T, Otagiri A, et al. Hypothalamic growth hormone secretagogue receptor regulates growth hormone secretion, feeding, and adiposity. J Clin Invest. 2002;109(11): [3] Wren AM, Seal LJ, Cohen MA, et al. Ghrelin enhances appetite and increases food intake in humans. J Clin Endocrinol Metab. 2001;86(12):5992. [4] Hadley SJ, Walsh BT. Gastrointestinal disturbances in anorexia nervosa and bulimia nervosa. Curr Drug Targets CNS Neurol Disord. 2003;2(1):1 9. [5] Murray SB, Anderson LK, Rockwell R, Griffiths S, Le grange D, Kaye WH. Adapting Family Based Treatment for Adolescent Anorexia Nervosa Across Higher Levels of Patient Care. Eat Disord. 2015;23(4): [6] Available at: ated Accessed July 16, 2015.

6 [7] Akamizu T, Iwakura H, Ariyasu H, et al. Repeated administration of ghrelin to patients with functional dyspepsia: its effects on food intake and appetite. Eur J Endocrinol. 2008;158(4): [8] Akamizu T, Takaya K, Irako T, et al. Pharmacokinetics, safety, and endocrine and appetite effects of ghrelin administration in young healthy subjects. Eur J Endocrinol. 2004;150(4): [9] Parker BA, Sturm K, Macintosh CG, Feinle C, Horowitz M, Chapman IM. Relation between food intake and visual analogue scale ratings of appetite and other sensations in healthy older and young subjects. Eur J Clin Nutr. 2004;58(2):212 8.