Soy Modulation of Immune Activation, LDL- Levels, and Lowering Inflammation by Pretzel Isoflavone Dietary Intervention

This study will significantly advance our knowledge of how dietary soy impacts lipid levels
and composition, metabolic parameters and inflammation in HIV+ patients treated with
anti-retroviral therapy (ART). HIV+ persons are at increased risk for CVD, and both HIV and
ART are associated with metabolic perturbations (including lipid disturbances) and chronic
inflammation. There is growing recognition that correcting these perturbations may improve
life expectancy. Two clinical trials, first a short-term single armed study, followed by a
two armed, placebo controlled, crossover clinical trial, will be used to address the
feasibility of a soy-based, functional food intervention and the impact of that intervention
on metabolic and immunomodulatory parameters. Daily pretzel dosing of two packets was
determined from prior clinical trials with soy bread in patients with prostate cancer. The
use of a food-based delivery vehicle has many advantages compared to using a dietary
supplement as it provides a strategy to deliver a complexity of bioactive compounds found
only in whole food ingredients. We hypothesize that the soy pretzel formulation will be well
tolerated with excellent adherence (>95%) among ART-treated HIV+ patients with moderate
hypercholesterolemia. The short-term dose confirmation study (n=20) will be a 6 week study
using a single intervention and single dose of soy pretzels to determine Grade 1 and 2
toxicities, compliance, and tolerability of soy pretzels in ART-treated HIV+ patients with
moderate hypercholesterolemia. Once, we have confirmed the short-term feasibility of soy
pretzels, a subsequent longer-term study will involve a 28 week randomized,
placebo-controlled, crossover trial (n=80) with soy and wheat (placebo) pretzels. Overall,
the short-term dose confirmation study will provide the necessary clinical data required to
move this intervention forward to the long-term placebo controlled trial. Both studies will
provide us with valuable biologic material to assess changes in cardiovascular and immune
biomarkers relevant to ART-treated HIV+ patients to facilitate future large-scale studies
investigating individual differences in soy isoflavone metabolism within this patient
population. Specifically, the short-term dose confirmation study will include those
participants who are screened and meet eligibility which will be determined using results
from a 12 hr fasting lipid panel which includes total cholesterol (TC), low density
lipoproteins (LDL), high density lipoproteins (HDL), and triglycerides; health history; and
the 2013 American College of Cardiology/ American Heart Association (ACC/AHA) Guidelines
cardiovascular risk calculator. Eligible participants will be enrolled and then instructed to
follow a legume-free diet (avoid beans, soy beans, lentils, bean sprouts, and peanuts) for
two weeks, abstain from other vitamins or dietary supplements, and follow the provided
standardized multivitamin regimen. Participants will return to clinic for a fasting blood
collection and submit a 24 hour urine collection at week 0. At the end of this visit,
participants will be instructed to consume one packet (10 pieces) of soy pretzels twice daily
and continue to follow the legume-free diet with the provided multivitamin regimen.
Participants will return after 4 weeks to obtain a second month's supply of study agents.
Subjects will return after a second 4 weeks for a fasting blood collection and to submit a
completed 24 hr urine collection. The subsequent placebo controlled study will include the
same criteria used for the earlier short-term study. Participants will be randomized to
either a soy pretzel intervention (1 packet of pretzels twice/day: total 20 pieces delivering
24g soy protein and ~60mg isoflavones) or a wheat pretzel intervention (placebo, 1 packet of
pretzels twice/day: total 20 pieces containing 0g soy protein and 0mg isoflavones) for 12
weeks before crossing over to the other pretzel intervention for a second 12 weeks. A
two-week washout period involving a legume-free diet and standardized multivitamin regimen,
similar to the short-term study, will precede each intervention period. Blood and 24-hour
urine will be collected at the specified time points to evaluate the sustained effects of the
soy pretzel intervention on biomarkers of cardiovascular risk, immune function, and
metabolites of isoflavone intervention. This study addresses an innovative approach of
utilizing a dietary soy snack food to reduce cardiac risk and to explore multiple drivers of
immune activation in HIV disease (pro-inflammatory lipids, microbial translocation, and the
cytokines they induce) increasing the likelihood that we will generate results that impact
clinically relevant indices of HIV disease progression.

Inclusion Criteria:

- Females and males aged 18 years or older.

- ACC/AHA 2013 Guidelines 10 year risk between <15%

- HIV-1 infection as documented by any licensed ELISA (enzyme-linked immunosorbent
assay) test kit and confirmed by Western blot at any time prior to study entry. HIV-1
culture, HIV-1 antigen, plasma HIV-1 ribonucleic acid (RNA), or a second antibody test
by a method other than ELISA is acceptable as an alternative confirmatory test.

- Receiving any stable Department of Health and Human Services (DHHS) recommended or
alternative antiretroviral regimen for at least the last 12 weeks prior to study
entry.

- Cumulative duration of antiretrovirals for at least 12 months at study entry.

- Documentation of at least 2 consecutive HIV-1 RNA levels of ≤50 copies/mL using any
standard commercially assay for at least 6 months prior to study entry. An isolated
(non-consecutive) HIV RNA > 50 copies/mL (but less than 400 copies/mL) within the
previous 12 months is permitted.

- Provides written informed consent and is capable of reading and comprehending the
informed consent.

- Meet Karnofsky performance status ≥70.

- Have a body mass index (BMI) between 20-35 kg/m2.

- Have a fasting total cholesterol levels of ≥200mg/dL AND either LDL cholesterol level
of 120 to 190mg/dL or a HDL ≤ 40 mg/dL

- Laboratory values obtained at screening:

- ANC (absolute neutrophil count) >1000/mm3

- Hemoglobin >11 g/dL

- Platelets ≥100,000/mm3

- Calculated creatinine clearance (CrCl) >60 mL/min, as estimated by the
Cockcroft-Gault equation

- ALT (alanine aminotransferase) <5 x ULN (upper limit of normal) or ALT <3 x ULN
and total bilirubin <1.5 x ULN Note: If the potential subject is taking an
atazanavir-containing regimen at the time of screening, total bilirubin ≤5 x ULN
is acceptable.

- Hgb A1c (Hemoglobin A1c) ≤6.5%

- Have no plans to alter antiretroviral therapy (including structured treatment
interruptions), diet (beyond soy intervention) or exercise regimens during the course
of the study.

- Agree to collect urine for 24 hours and have blood collected, at specified time
points.

- Agree to abstain from use of herbal or dietary supplements during the 6 weeks for the
short-term study or 28 weeks for the placebo-controlled study or any other supplements
that might interact with dietary soy intervention.

- Agree to follow a daily vitamin and mineral supplement regimen for 6 weeks for the
short-term study or 28 weeks for the placebo-controlled study.

- Agree to abstain from legume foods or products made from these ingredients which are
known to be high in isoflavones for 6 weeks or 28 weeks:

Soy: Edamame, Miso, Soy cheese, Tofu, Tempeh, Protein bars, Soymilk, Natto, Soy meat
substitutes Beans: Navy, Kidney, Green beans, Lima, Pinto, Black beans, Cannellini, and
Chickpeas Peas: Green, Snow, Black-eyed Peanuts: Peanuts, Peanut butter (1 tablespoon/week
permitted) Sprouts: Alfalfa, Clover, Mung bean, Soybean

Exclusion Criteria:

- Need (or anticipated need in the next 24 weeks) for lipid modification pharmacotherapy
or hypolipidemics (e.g., statins or fibrates) or hypoglycemic therapy.

- A clinically important illness within 14 days prior to study entry not explicitly
excluded by the protocol, a physical or psychiatric disability, or a laboratory
abnormality that might place the subject at increased risk by being exposed to the
medications in this study or which might confound the interpretation of this
investigation.

- Chronic hepatitis B or C infection Note: Participants who have been treated for their
hepatitis C and have achieved a sustained virologic response (SVR) of 12 may
participate.

- Any active or chronic uncontrolled inflammatory condition.

- Diarrhea or vomiting of Grade ≥ 2 within 14 days prior to study entry.

- An active AIDS-defining opportunistic infection or disease (for the purpose of this
study, a cluster of differentiation 4 (CD4) count <200 cells/mm3 in the absence of any
other AIDS-defining indicator condition is not considered an AIDS-defining event).

- Inability to maintain adherence to study schedule or communicate with study personnel.

- Current alcohol or recreational drug use which in the investigator's opinion
interferes with the subject's ability to comply with dosing schedule and protocol
evaluations.

- Any change in the last 24 weeks in therapy with prescription omega-3 fatty acids (>2
gram/day of Lovaza®), fibrates, or prescription niacin. Therapy with OTC (over the
counter) omega 3 fatty acids or with ≤ 2 g Lovaza® is allowed. Any statin therapy for
longer than 14 days received in the last 24 weeks is exclusionary.

- Have had a full treatment course/regimen of antibiotics 6 months prior to start of
study.

- Known sensitivity or allergy or intolerance to wheat, soy, or any of the ingredients
found in pretzels (yeast, soy bean oil, palm oil, or diastase enzymes).

- Have had a malignancy of any kind or ongoing chemotherapy, radiation therapy, or other
cancer-related treatment.

- Concurrent use of immunosuppressant medications, including but not limited to
immunomodulating agents, steroids, and chronic anti-inflammatory agents.

- Active metabolic or digestive illness including malabsorptive disorders, diabetes
mellitus (indicated by Hgb A1c of ≥6.8% or on exogenous insulin therapy), renal
insufficiency, hepatic insufficiency, hyper- or hypothyroidism, or short bowel
syndrome, have an active or a recent history of any condition that causes altered
immunity, co-morbid cardiac, pulmonary, renal, neurologic, and endocrine.

- Known underlying myositis or muscle disease.

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, hypertension, or psychiatric illness/social situation that would limit
compliance with study requirements.

- Lack of regular access to a household freezer (for pretzel storage).