Effect of a 1-Year Controlled Lifestyle Intervention on Body Weight and Other Risk Markers (the Healthy Lifestyle Community Programme, Cohort 2)

Effect of a controlled lifestyle intervention on medication use and costs: The Healthy Lifestyle Community Program (cohort 2)

Background: Establishing a healthy lifestyle has a great potential to reduce the prevalence of non-communicable diseases (NCDs) and their risk factors. NCDs contribute immensely to the economic costs of the health care system arising from therapy, medication use, and productivity loss. Aim: The aim of this study was to evaluate the effect of the Healthy Lifestyle Community Program (cohort 2; HLCP-2) on medication use and consequently on medication costs for selected NCDs (diabetes, hypertension, and dyslipidemia). Methods: Data stem from a 24-month non-randomised, controlled intervention trial aiming to improve risk factors for NCDs. Participants completed questionnaires at six measurement time points assessing medication use, from which costs were calculated. The following medication groups were included in the analysis as NCD medication: glucose-lowering medications (GLM), antihypertensive drugs (AHD) and lipid-lowering drugs (LLD). Statistical tests for inter- and intra-group comparison and multiple regression analysis were performed. Results: In total, 118 participants (intervention group [IG]: n = 79; control group [CG]: n = 39) were considered. Compared to baseline medication use decreased slightly in the IG and increased in the CG. Costs for NCD medication were significantly lower in the IG than in the CG after 6 (p = 0.004), 12 (p = 0.040), 18 (p = 0.003) and 24 months (p = 0.008). After multiple regression analysis and adjusting for confounders, change of costs differed significantly between the groups in all final models. Conclusion: The HLCP-2 was able to moderately prevent an increase of medication use and thus reduce costs for medication to treat NCDs with the greatest impact on AHD.Trial registrationGerman Clinical Trials Register DRKS (www.drks.de; reference: DRKS00018775).

Impact of the Healthy Lifestyle Community Program (HLCP-3) on Trimethylamine N-Oxide (TMAO) and Risk Profile Parameters Related to Lifestyle Diseases During the Six Months Following an Intervention Study

RATIONALE

The dietary components choline, betaine, and L-carnitine are converted by intestinal microbiota into the molecule trimethylamine (TMA). In the human liver, hepatic flavin-containing monooxygenase 3 oxidizes TMA to trimethylamine-N-oxide (TMAO). TMAO is considered a candidate marker for the risk of cardiovascular disease.

METHODOLOGY

The Healthy Lifestyle Community Program cohort 3 (HLCP-3) intervention was conducted with participants recruited from the general population in Germany (intervention: n = 99; control: n = 48). The intervention included intensive educational workshops, seminars, and coaching activities. The assessment was conducted using a complete case analysis (CCA) of the participants. The intervention was carried out for a ten-week intensive phase and an alumni phase. The interventional program emphasizes adopting a healthy plant-based diet and reducing meat consumption, as adherence to such a diet may lead to lowering TMAO levels. Additionally, it provides general recommendations about physical activity, stress management, and community support. The control group did not receive any intervention. TMAO was evaluated using stable isotope dilution liquid chromatography, and tandem mass spectrometry was used to measure fasting plasma levels of TMAO.

OBJECTIVES

The present study aimed to determine the impact of the Healthy Lifestyle Community Program (HLCP-3) on risk profiles for lifestyle-related diseases and TMAO plasma levels.

RESULTS

Significant decreases in most risk profile parameters were detected, and a non-significant decrease in plasma TMAO levels was observed in the intervention group (0.37 (-1.33; 0.59) µmol/L). Furthermore, for the intervention group, after a six-month follow-up period, there was a significant negative correlation between higher healthy plant diet index (hPDI) scores and a decrease in plasma TMAO (ß = -0.200, p = 0.027). Additionally, a significant negative correlation was observed between the TMAO level and the scores for adherence to the plant diet index (PDI) (r = -0.195; p = 0.023).

CONCLUSIONS

HLCP-3 is effective at improving adherence to a plant-based diet and improving risk profile parameters. However, long-term interventions involving stricter dietary programs in the sense of a plant-based diet are recommended if significant decreases in TMAO levels are to be obtained.

Management of male obesity-related secondary hypogonadism: A clinical update

The global obesity pandemic has resulted in a rise in the prevalence of male obesity-related secondary hypogonadism (MOSH) with emerging evidence on the role of testosterone therapy. We aim to provide an updated and practical approach towards its management. We did a comprehensive literature search across MEDLINE (via PubMed), Scopus, and Google Scholar databases using the keywords "MOSH" OR "Obesity-related hypogonadism" OR "Testosterone replacement therapy" OR "Selective estrogen receptor modulator" OR "SERM" OR "Guidelines on male hypogonadism" as well as a manual search of references within the articles. A narrative review based on available evidence, recommendations and their practical implications was done. Although weight loss is the ideal therapeutic strategy for patients with MOSH, achievement of significant weight reduction is usually difficult with lifestyle changes alone in real-world practice. Therefore, androgen administration is often necessary in the management of hypogonadism in patients with MOSH which also improves many other comorbidities related to obesity. However, there is conflicting evidence for the appropriate use of testosterone replacement therapy (TRT), and it can also be associated with complications. This evidence-based review updates the available evidence including the very recently published results of the TRAVERSE trial and provides comprehensive clinical practice pearls for the management of patients with MOSH. Before starting testosterone replacement in functional hypogonadism of obesity, it would be desirable to initiate lifestyle modification to ensure weight reduction. TRT should be coupled with the management of other comorbidities related to obesity in MOSH patients. Balancing the risks and benefits of TRT should be considered in every patient before and during long-term management.

Health Economic Evaluation of a Controlled Lifestyle Intervention: The Healthy Lifestyle Community Program (Cohort 2; HLCP-2)

Non-communicable diseases (NCD) are associated with high costs for healthcare systems. We evaluated changes in total costs, comprising direct and indirect costs, due to a 24-month non-randomized, controlled lifestyle intervention trial with six measurement time points aiming to improve the risk profile for NCDs. Overall, 187 individuals from the general population aged ≥18 years were assigned to either the intervention group (IG; n = 112), receiving a 10-week intensive lifestyle intervention focusing on a healthy, plant-based diet; physical activity; stress management; and community support, followed by a 22-month follow-up phase including monthly seminars, or a control group (CG; n = 75) without intervention. The complete data sets of 118 participants (IG: n = 79; CG: n = 39) were analyzed. At baseline, total costs per person amounted to 67.80 ± 69.17 EUR in the IG and 48.73 ± 54.41 EUR in the CG per week. The reduction in total costs was significantly greater in the IG compared to the CG after 10 weeks (p = 0.012) and 6 months (p = 0.004), whereas direct costs differed significantly after 10 weeks (p = 0.017), 6 months (p = 0.041) and 12 months (p = 0.012) between the groups. The HLCP-2 was able to reduce health-related economic costs, primarily due to the reduction in direct costs.

Centralized health management based on hot spring resort improves physical examination indicators and sleep quality in people at high risk of chronic diseases: a randomized controlled trial

We study the effects of centralized health management based on hot spring resorts on the physical examination index and sleep quality of people at high risk of chronic diseases. We recruited 114 volunteers at high risk of chronic diseases. We then divided them into 57 in the intervention group and 57 in the control group. The intervention group collectively received 4 weeks (28 days) of comprehensive health management interventions at Tongjing Hotspring Resort, including regular schedules, balanced diet, appropriate exercise, targeted health education, etc. The main outcomes are physical examination indicators (height, weight, waist circumference, blood pressure, lipids, and glucose) and sleep quality. Both groups underwent a questionnaire and physical examination at baseline, 2 weeks and 4 weeks. Intragroup comparisons grouped by exposure criteria showed decreases in BMI, waist circumference, triglycerides, total cholesterol, and blood glucose in the intervention group at both 2 and 4 weeks (all P < 0.05); however, in the control group, only triglycerides decreased at 4 weeks (P < 0.05). Intergroup comparisons showed BMI and waist circumference were significantly lower in the intervention group than in the control group at 4 weeks (all P < 0.05). Intragroup comparisons of insomnia severity index (ISI) scores showed a significant decrease in the intervention group at both 2 and 4 weeks (all P < 0.001) with no significant change in the control group (P > 0.05). Intergroup comparisons showed that the insomnia severity index (ISI) scores were significantly higher in the intervention group than in the control group at baseline (P = 0.006) but became significantly lower than the control group at 2 and 4 weeks (all P < 0.001). Thus, this pattern significantly improved BMI, waist circumference, triglycerides, and sleep in the intervention group. TRIAL REGISTRATION NUMBER: Chinese Clinical Trials Registry: ChiCTR2100053201, registered 14 Nov 2021. (Retroactive Registration).

Combined Effect of Leisure-Time Physical Activity and Sedentary Behavior on Abdominal Obesity in ELSA-Brasil Participants

INTRODUCTION

Abdominal obesity is a pattern of obesity that has been considered a public health problem. Physical activity is considered an important factor for the prevention of abdominal obesity. Increased time in sedentary behavior has been associated with negative health outcomes, including abdominal obesity.

OBJECTIVE

The aim of this study was to investigate which combination of leisure-time physical activity and sedentary behavior contributes most to the prevention of abdominal obesity in adults participating in ELSA-Brasil (Longitudinal Study of Adult Health).

METHODS

The study was cross-sectional and participants from the first follow-up of the ELSA-Brasil cohort (2012-2014) were analyzed. The independent variables were physical activity, assessed by IPAQ, and sedentary behavior, assessed by a standard questionnaire applied in ELSA-Brasil; the dependent variable was abdominal obesity, determined by waist circumference. The covariates analyzed were the following: age, education, binge drinking, smoking and menopause. The associations between the dependent variable and the independent variables were analyzed using logistic regression. The odds ratio with 95 CI% was estimated.

RESULTS

For men, the combinations were more significant when they were more physically active and spent less time on the sedentary behaviors analyzed, on both a weekday and a weekend day. For menopausal women, both younger and older, all associations of the combinations between sufficient leisure-time physical activity and little time spent in sedentary behaviors contributed to the prevention of abdominal obesity. In non-menopausal women, positive associations were observed in almost all combinations between leisure-time physical activity and sedentary behaviors, with some results that were not statistically significant among younger women.

CONCLUSIONS

Our results showed that being sufficiently active and reducing the time spent in sedentary behavior was the combination that contributed the most to the prevention of abdominal obesity, both in men and women.

The healthful plant-based diet index as a tool for obesity prevention-The healthy lifestyle community program cohort 3 study

Background

World-wide the prevalence of obesity is high, and promoting a shift toward more healthful and more plant-based dietary patterns appears to be one promising strategy to address this issue. A dietary score to assess adherence to a healthy plant-based diet is the healthful plant-based diet index. While there is evidence from cohort studies that an increased healthful plant-based diet index is associated with improved risk markers, evidence from intervention studies is still lacking.

Methods

A lifestyle intervention was conducted with mostly middle-aged and elderly participants from the general population (n = 115). The intervention consisted of a 16-month lifestyle program focusing on a healthy plant-based diet, physical activity, stress management, and community support.

Results

After 10 weeks, significant improvements were seen in dietary quality, body weight, body mass index, waist circumference, total cholesterol, measured and calculated low-density lipoprotein (LDL) cholesterol, oxidized LDL particles, non-high-density lipoprotein cholesterol, remnant cholesterol, glucose, insulin, blood pressure, and pulse pressure. After 16 months, significant decreases were seen in body weight (-1.8 kg), body mass index (-0.6 kg/m2), and measured LDL cholesterol (-12 mg/dl). Increases in the healthful plant-based diet index were associated with risk marker improvements.

Conclusions

The recommendation of moving toward a plant-based diet appears acceptable and actionable and may improve body weight. The healthful plant-based diet index can be a useful parameter for intervention studies.

Effects of the healthy lifestyle community program (cohort 1) on stress-eating and weight change after 8 weeks: a controlled study

Stress-eating (eating more or more unhealthily in order to accommodate to stress), contributes to the development and maintenance of obesity. The effect of comprehensive weight loss interventions on changes in stress-eating as well as the contributing role of stress-eating on weight reduction has not been examined. The impact of the 8-week intensive phase of the Healthy Lifestyle Community Programme (HLCP, cohort 1) on emotional, external and restrained eating, as expressions of stress-eating was evaluated in a non-randomized controlled trial. Intervention: 14 seminars (twice per week, including practical units), complemented by stress-regulation and cooking workshops and coaching sessions empowering participants to change their behaviour towards a healthy plant-based diet (ad libitum), stress regulation, regular exercise and to focus on social support. Participants were recruited from the general population. In the intervention group, 91 participants (IG; age: 56 ± 10, 77% female) and in the control group, 52 (CG; age: 62 ± 14, 57% female) were enrolled. At baseline, participants of the IG reported higher levels of stress (9.7 ± 5.4 points [P] vs. 7.6 ± 6.2; p < 0.011), and of emotional eating (27.9 ± 9.4 vs. 20.0 ± 7.1; p < 0.001) and external eating (29.1 ± 4.9 vs. 25.5 ± 5.6; p < 0.001) than participants of the CG. Within 8 weeks, in the IG, scores of emotional eating (- 3.5 ± 5.4 P) and external eating significantly decreased (= - 2.0 ± 3.8 P), while restrained eating increased (2.7 ± 5.0 P; p for all < 0.001). Weight change was negatively correlated with change of external eating (R2 = 0.045; CC = - 0.285; p = 0.014), indicating that a greater weight change was associated with a smaller change of external eating. This is the first study to prospectively investigate the role of stress-eating on the weight reduction effect of comprehensive lifestyle interventions. Our data confirm that overweight is associated with EE and external eating and suggest that the HLCP is capable to reduce both, weight and stress-eating.Trial registration: German Clinical Trials Register (DRKS; reference: DRKS00018821; September 18th 2019; retrospectively registered).

Effects of a vegetarian diet combined with aerobic exercise on glycemic control, insulin resistance, and body composition: a systematic review and meta-analysis

BACKGROUND

Vegetarian diets and aerobic exercise are increasingly accepted as a common way to improve lifestyle. Several studies have shown that vegetarian diets combined with aerobic exercise interventions have a significant effect on preventing and reducing the risk of metabolic diseases.

METHODS

A search of the PubMed, EBSCO, Embase, CENTRAL, and Web of Science databases was conducted for comparative studies of pre- and post-vegetarian diet adoption combined with aerobic exercise interventions on glycemic control and body composition. Qualitative reviews and meta-analyses of fixed and random effects were conducted to pool available data. The results were validated by sensitivity analysis.

RESULTS

A total of 27 studies were selected for meta-analysis. Combining the studies included in the meta-analysis showed a mean difference for homeostasis model assessment of insulin resistance of - 0.75 (- 1.08 to - 0.42), fasting plasma glucose of - 0.27(- 0.30 to - 0.23), waist circumference of - 1.10 (- 5.06 to 2.86) and body mass index of - 0.70 (- 1.38 to - 0.01).

CONCLUSION

In summary, our findings suggest that participants who adopted a vegetarian diet combined with aerobic exercise intervention had significantly lower fasting plasma glucose and insulin levels and improved body composition compared to preintervention participants.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Exploratory analysis of the effect of a controlled lifestyle intervention on inflammatory markers - the Healthy Lifestyle Community Programme (cohort 2)

BACKGROUND

Chronic low-grade inflammation is associated with an increased risk of chronic disease and mortality. The objective of the study was to test the effect of a healthy lifestyle intervention on biomarkers of inflammation (among other risk markers).

METHODS

We conducted a non-randomized controlled trial with mostly middle-aged and elderly participants from the general population in rural northwest Germany (intervention: n = 114; control: n = 87). The intervention consisted of a 1-year lifestyle programme focusing on diet (largely plant-based; strongest emphasis), physical activity, stress management, and social support. High-sensitivity C-reactive protein (hs-CRP) was assessed at baseline, 10 weeks, 6 months, and 1 year. Homocysteine (Hcy) was assessed at baseline, 10 weeks, and 1 year. Adiponectin (Apn) was assessed at baseline and 10 weeks. An exploratory analysis of these inflammatory markers assessing the between-group differences with ANCOVA was conducted.

RESULTS

The 1-year trajectory of hs-CRP was significantly lower in the intervention group compared to control (between-group difference: -0.8 (95% CI -1.2, -0.3) mg/l; p = 0.001; adjusted for baseline). The 1-year trajectory of Hcy was non-significantly higher in the intervention compared to control (between-group difference: 0.2 (95% CI -0.3, 0.7) µmol/l; p = 0.439; adjusted for baseline). From baseline to 10 weeks, Apn decreased significantly more in the intervention group compared to control (between-group difference: -1.6 (95% CI -2.7, -0.5) µg/ml; p = 0.004; adjusted for baseline).

CONCLUSIONS

Our study shows that healthy lifestyle changes can lower hs-CRP and Apn levels and are unlikely to significantly affect Hcy levels within 1 year.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; reference: DRKS00018775 , registered 12 Sept 2019; retrospectively registered; www.drks.de ).

Association of physical activity and trajectories of physical activity with cardiovascular disease

INTRODUCTION

Prolonged sedentary life existence is associated with increased incidence of cardiovascular disease (CVD), coronary heart disease (CHD), obesity, type 2 diabetes mellitus (T2DM), hypertension, heart failure (HF), and all-cause mortality. On the contrary, regular exercise is known from antiquity to be associated with beneficial cardiovascular (CV) effects and decreased mortality.

AREAS COVERED

The cardiovascular (CV) benefits of exercise have been confirmed by many studies, but the trajectories of the different modes of PA are not well recognized. In order to examine the different modalities of exercise and its long-term trajectories, a Medline search of the English literature was conducted between 2015 and 2022 and 60 pertinent papers were selected for review.

EXPERT OPINION

Careful review of the selected papers showed that the beneficial CV effects of PA are mediated through several favorable modifications of molecular and clinical factors. Also, any type of physical activity in conjunction with lifestyle adjustments is associated with decreased incidence of CVD, CHD, obesity, T2DM, hypertension, HF, and all-cause mortality. In addition, the long-term trajectories regarding the duration and the level of exercise are associated with greater beneficial CV effects, with even the resumption of discontinued exercise can lead to beneficial CV effects.

Associations of Cardiorespiratory Fitness With Estimated Remnant Cholesterol and Non-High-Density Lipoprotein Cholesterol in Healthy Men

Remnant cholesterol (RC) and non-high-density lipoprotein cholesterol (non-HDL-C) may contribute to the residual risk for atherosclerotic cardiovascular disease. High cardiorespiratory fitness (CRF) is associated with favorable traditional lipid profiles, but its relation with RC and non-HDL-C remains unclear. We analyzed cross-sectional data on 4,613 healthy men (mean age 49 years). CRF was measured using peak oxygen uptake during incremental exercise testing and categorized into quartiles. RC was estimated as total cholesterol minus HDL-C and low-density lipoprotein cholesterol, and elevated RC was defined as ≥38 mg/100 ml (90 percentile). Non-HDL-C was calculated as total cholesterol minus HDL-C, and high non-HLD-C was defined as ≥190 mg/100 ml. CRF was inversely associated with RC (β -0.31, 95% confidence interval [CI] -0.39 to -0.24) and non-HDL-C (β -0.34, 95% CI -0.57 to -0.11) after adjustment for several risk factors. Each metabolic equivalent increment in CRF was associated with lower odds of having elevated RC (odds ratio [OR] 0.85, 95% CI 0.77 to 0.93) and non-HDL-C (OR 0.93, 95% CI 0.85 to 1.00) in multivariable analysis. Compared with the bottom quartile, the top quartile of CRF had significantly lower odds of elevated RC (OR 0.63, 95% CI 0.45 to 0.88) and non-HDL-C (OR 0.68, 95% CI 0.51 to 0.91). In conclusion, higher CRF was independently associated with lower levels of RC and non-HDL-C and lower odds of the prevalence of elevated RC and non-HDL-C in healthy men.

The value of dietary plant protein in older people

PURPOSE OF REVIEW

The current review provides an update on recent research regarding plant-based protein and their nutritional quality for older people.

RECENT FINDINGS

There is growing evidence that plant-based proteins may be a valuable strategy for older people to prevent the health risks associated with consuming animal products and to promote better protein intake, as plant-based protein sources are rich in fibres and micronutrients. Although plant-based proteins are less anabolic than animal-derived proteins due to lower digestibility and deficiencies in some essential amino acids, several innovations in food processing and nutritional strategies have been developed to improve the quality of plant-based proteins. For example, the use of protein blends or green-processes as fermentation or germination could improve the nutritional qualities of plant-based foods that could be beneficial for older people, especially to prevent sarcopenia or metabolic disorders such as diabetes, obesity and cardiovascular diseases.

SUMMARY

The use of plant-based protein sources could help older people diversify their protein sources and more easily meet recommended nutritional intake. Recent literature highlights several health benefits associated with increased consumption of vegetable foods. However, their efficiency on postprandial muscle protein synthesis remains to be evaluated and long-term studies are needed.

Healthy lifestyle changes favourably affect common carotid intima-media thickness: the Healthy Lifestyle Community Programme (cohort 2)

Common carotid intima-media thickness (ccIMT) progression is a risk marker for cardiovascular disease (CVD), whereas healthy lifestyle habits are associated with lower ccIMT. The objective of the present study was to test whether a healthy lifestyle intervention can beneficially affect ccIMT progression. A community-based non-randomised, controlled lifestyle intervention was conducted, focusing on a predominantly plant-based diet (strongest emphasis), physical activity, stress management and social health. Assessments of ccIMT were made at baseline, 6 months and 1 year. Participants had an average age of 57 years and were recruited from the general population in rural northwest Germany (intervention: n 114; control: n 87). From baseline to 1 year, mean ccIMT significantly increased in both the intervention (0⋅026 [95 % CI 0⋅012, 0⋅039] mm) and control group (0⋅045 [95 % CI 0⋅033, 0⋅056] mm). The 1-year trajectory of mean ccIMT was lower in the intervention group (P = 0⋅022; adjusted for baseline). In a subgroup analysis with participants with high baseline mean ccIMT (≥0⋅800 mm), mean ccIMT non-significantly decreased in the intervention group (-0⋅016 [95 % CI -0⋅050, 0⋅017] mm; n 18) and significantly increased in the control group (0⋅065 [95 % CI 0⋅033, 0⋅096] mm; n 12). In the subgroup, the 1-year trajectory of mean ccIMT was significantly lower in the intervention group (between-group difference: -0⋅051 [95 % CI -0⋅075, -0⋅027] mm; P < 0⋅001; adjusted for baseline). The results indicate that healthy lifestyle changes may beneficially affect ccIMT within 1 year, particularly if baseline ccIMT is high.

Eight Weeks of Lifestyle Change: What are the Effects of the Healthy Lifestyle Community Programme (Cohort 1) on Cortisol Awakening Response (CAR) and Perceived Stress?

Background: Stress and cortisol dysregulation are linked to NCDs. Moreover, stress favours unhealthy lifestyle patterns, which increase the risk for NCDs. The role of the Cortisol Awakening Response (CAR) and the effect of lifestyle interventions on the same remain unclear. Methods: The impact of the intensive 8-week phase of the Healthy Lifestyle Community Programme (HLCP, cohort 1) on parameters of the CAR, ie cortisol values 0 (sample [S]1), 30), 45 and 60 minutes post-awakening, average peak, S1-peak delta and area under the increase curve (AUCI), and perceived stress levels (PSL) was evaluated in a non-randomized, controlled trial. Covariates of the CAR (eg sleep measures) and irregularities in sampling were assessed. The intervention focussed on stress management, a healthy diet, regular exercise, and social support. Participants were recruited from the general population. Multiple linear regression analyses were conducted. Results: 97 participants (age: 56 ± 10 years; 71% female), with 68 in the intervention group (IG; age: 55 ± 8, 77% female) and 29 participants in the control group (CG; age: 59 ± 12, 59% female), were included in the analysis. The baseline characteristics of both groups were comparable, except participants of IG were younger. On average, the PSL at baseline was low in both groups (IG: 9.7 ± 5.4 points; CG: 8.5 ± 6.9 points; p = .165), but 22% (n = 15) in the IG and 20% (n = 6) in the CG reported a high PSL. Most participants reported irregularities in CAR sampling, eg interruption of sleep (IG: 80% CG: 81%). After 8 weeks, most CAR parameters and the PSL decreased in the IG and CG, resulting in no differences of change between the groups. In the IG only, a decrease of PSL was linked to an increase of CAR parameters, eg AUCI (correlation coefficient = −0.307; p = .017). Conclusion: The HLCP may potentially reduce PSL and change the CAR, but results cannot be clearly attributed to the programme. Methodological challenges and multiple confounders, limit suitability of the CAR in the context of lifestyle interventions. Other measures (eg hair-cortisol) may give further insights. Trial registration: German Clinical Trials Register (DRKS); DRKS00018821; www.drks.de