Balanced Nutritional Diet Intervention on Body Composition Among Different FTO RS9939609 Gene in Obese Young Women In Bandung, Indonesia: A Randomised Controlled Trial
Phase: NA
Conditions: Obese Women
Sponsor: Universitas Padjadjaran

 
Balanced Nutritional Diet Intervention on Body 
Composition Among Different FTO RS9939609 Gene 
in Obese Young Women In Bandung, Indonesia: A 
Randomised Controlled Trial 
 
Update 10 October 2023 
 
 

FL/02-06 
Clinical Trial Form 
 
No. Register: 
2 
3 
0 
7 
0 
6 
1 
0 
8 
9 
A. 
General information 
1. 
Principal Researcher (Name and 
title) 
Putri Novitasari, S.Gz., M.Si 
Skills/Specialization 
Nutrition Science 
Position/Position 
IPB Doctoral Student (S3) 
Tel. House: ─ 
MOBILE PHONE: 
08112227291 
e-mail: putrinovitasarigizi@gmail.com 
2. 
Origin of Institution: Non-Unpad 
Doctoral Study Program in Nutritional Sciences 
IPB University 
Tel.: (0251) 8622642 
Fax:─ 
e-mail: pascasarjanagizi@apps.ipb.ac.id 
Sponsors 
(Individual/Private/National 
grant/International grant) 
Individual 
Clinical Monitor 
Dr. Lucky Angkawijaya Roring, M.Pd., AIFO 
Other Supervisors/Researchers: 
1. Prof. Dr. Rimbawan 
2. Prof. Dr. Ir. Hardinsyah, MS 
3. Prof. Dr. Ir. Hadi Riyadi, MS 
3. 
Research Title: The Effect of a Balanced Nutritional Diet on Cardiovascular Risk Factors Among Two 
Types of FTO Gene rs9939609 Obese Young Adult Women 
4. 
Multicenter 
 
Yes 
Primary Research Center:  
Satellite Research Flashlight:  
√ No 
5. 
Study 
√ Not cooperation 
National cooperation 
International, number of countries please specify: 
Involving a foreign Chief Researcher (attach permission, Institutional MoU, Researcher visa) 
6. 
Filled in if a foreign research leader is involved 
No. 
Name, title, institution 
of the foreign Research 
Chair 
Duties & Functions 
Tel., Fax, HP, e-mail: 
1. 
 
 
 
2. 
 
 
 
3. 
 
 
 
 
7. 
Research Place (Mention the name of the hospital, treatment room, polyclinic, or other health 
service location): Screening of potential subjects, signing of the INFORMED CONSENT, collection of 
subject blood specimens, and data collection were carried out at the Health Services (Polyclinic), 
Universitas Pendidikan Indonesia  
Address: Jl. Dr. Setiabudhi No. 229, Isola, Sukasari, Bandung City 
The doctor responsible for examining the subject, taking samples and managing if any side effects 
occur: Dr Lucky Angkawijaya Roring, M.Pd., AIFO 
 

If necessary, collection of additional or incomplete data is carried out online/by telephone or at the 
subject's place if the subject permits. 
 
Blood specimen testing was carried out at the Molecular Genetics Laboratory, Faculty of Medicine, 
Padjajaran University. 
8. 
Research Time Plan: 
± 4 months 
Starting: 
November 
2023 
Completed: February 2024 
 
 
9. 
Data Collection Time Starting: November 2023 to February 2024 
 
10. 
Has This Protocol Been Submitted to Another Ethics Commission?  
Yes 
 If yes, attach a photocopy of the document! 
Accepted 
Rejected 
√ No 
11. 
Allocation and Details of Research Funds (Human Resources, Consumables, etc.): 
 
No. 
Type of Spending 
Component 
Fee Required 
1 
Material 
ATK 
IDR 500,000 
2 
Material 
Diet Procurement (20x3x30x45,000) 
IDR 81,000,000 
3 
Material 
Elisa Kit (IL-6; hs-CRP; adiponectin) 
IDR 23,532,000 
4 
Material 
DNA isolation kit (40x200,000) 
IDR 8,000,000 
5 
Material 
Primary (1x400,000) 
IDR 400,000 
6 
Material 
Primary Design Services (1x150,000) 
IDR 150,000 
7 
Material 
Subject Reward (40x35,000) 
IDR 1,400,000 
8 
Data collection 
FGD research preparation (5x105,000) 
IDR 525,000 
9 
Data collection 
Survey Officer's Honorarium (Screening: 
40x8,000) 
IDR 320,000 
10 
Data collection 
Temporary 
Blood 
Glucose 
Test 
(40x18,000) 
IDR 720,000 
11 
Data collection 
Researcher Administration Honoraria 
IDR 300,000 
12 
Data collection 
Transport subject + officers (43x25,000x2) 
IDR 2,150,000 
13 
Data collection 
Data collection meetings (5x105,000) 
IDR 525,000 
14 
Equipment Rental 
Research Equipment (2x350,000) 
IDR 700,000 
15 
Specimen Analysis 
PCR Gene Amplification (42x100,000) 
IDR 4,200,000 
16 
Specimen Analysis 
Sequencing (42x350,000) + (42x10,000) 
IDR 15,120,000 
17 
Specimen Analysis 
Electrophoresis (42x50,000) 
IDR 2,100,000 
18 
Specimen Analysis 
Elisa Analysis (3x1,800,000) 
IDR 5,400,000 
19 
Data analysis 
Honor Data Processor 
IDR 1,540,000 
20 
Data analysis 
Meeting Consumption Costs (5x105,000) 
IDR 525,000 
21 
Reporting and Output 
International Seminar Fees 
IDR 3,000,000 
22 
Reporting and Output 
International Scientific Publication Fees 
IDR 3,500,000 
Total 
IDR 155,607,000 
 
 
B. 
 
 
Clinical Trials 
Research methods 
1. 
A summary of the research proposal includes the reason/motivation for conducting the research, 
the aims/objectives and benefits of the research, as well as the risks that may arise along with how 
to overcome them (written in language that is easy for non-doctors to understand): 
 
Reason/Motivation for Conducting Research: 
One nutritional strategy for obese individuals to lose weight is diet modification. Previous 
studies have shown that moderate weight loss (5–10% of initial body weight) achieved through 
lifestyle changes is associated with improvements in the cardiometabolic abnormalities 
characteristic of obesity (Espeland et al. 2007; Zomer et al. 2016). There have been studies and meta-

analyses that examine FTO gene polymorphisms coupled with certain types of dietary intervention 
which are then associated with changes in nutritional status, body composition, and various 
inflammatory and hormonal biomarkers in obese subjects (Razquin et al. 2010; De Luis et al. 2012b; 
De Luis et al. 2015a; De Luis et al. 2015b; Luglio et al. 2017; Di Renzo et al. 2018; De Luis et al. 2020; 
Parastouei et al. al. 2020), however, some things are still unclear and limited. Apart from that, no 
one has ever linked the FTO gene polymorphism to the Balanced Nutrition Diet intervention which 
is the reference in Indonesia, as well as its effect on cardiovascular risk. 
 
Research purposes: 
General purpose: 
Examining the Effect of a Balanced Nutritional Diet on Cardiovascular Risk Factors Among Two 
Types of FTO rs9939609 Gene in Obese Young Women. 
 
Special purpose: 
1. Analyze differences in the body composition of obese young women between A allele carriers 
(AC) and TT allele homozygous (TH) groups after Balanced Nutrition Diet intervention 
2. Analyze differences in biomarkers of inflammation related to cardiovascular risk (interleukin (IL-
6), high-sensitivity CRP (hs-CRP), and adiponectin (ADP)) of obese young women between A allele 
carriers (AC) and TT allele homozygous (TH) groups after Balanced Nutrition Diet intervention 
 
Benefits of research: 
For research subjects, subjects can find out the allele type of the FTO rs9939609 gene 
themselves as an illustration of genes related to obesity and that can be used as a basis for precision 
nutrition interventions and will receive nutritional education about balanced nutrition. For the 
public, it is hoped that this research can increase knowledge about consumption recommendations, 
especially to normalize nutritional status and reduce the risk of cardiovascular disease by improving 
health status, especially for young adult women. For educational institutions, it is hoped that this 
research will provide new scientific evidence in the field of nutrigenomics regarding the interaction 
of genes and diet influencing the risk of obesity and cardiovascular disease. For the government, it 
is hoped that it can become a reference for making a policy to reduce obesity cases in Indonesia. 
 
Number of Research Subjects: 
This research uses a hypothesis testing formula for 2 independent samples based on 
Sastroasmoro & Ismael (2014): 
=
=
 
The results of calculations using data from previous research (De Luis et al. 2015b) resulted in 
7 people. This study used 4 groups, namely 2 control groups and 2 intervention groups, adding an 
anticipated dropout of 50%, the total number of subjects was at least 44 people or 11 people per 
group. 
Information: 
 
n = minimum number of subjects 
Zα = type I error (1.96) 
Zb = type II error (1.28; power 90) 
S = standard deviation of the two groups 
X1 – X2 = desired clinical difference (difference in weight between Allele T and Allele A) 
Research by De Luis et al. (2015b) is a consideration for the expected weight loss of subjects 
in this study, namely assuming a weight loss of ±1 kg in A allele carriers and ±0.35 kg in homozygous 
T subjects after 1 month of intervention with the balanced nutritional diet provided. 
 
 
How to Choose Research Subjects 

Inclusion Criteria: 1) Obese women (body fat percentage >35%) who have light physical activity based 
on PAL (can select prospective subjects who have participated in preliminary research to 
completion); 2) Sundanese ethnicity (father, mother, grandfather, grandmother originally from West 
Java); 3) normal fasting blood pressure and blood sugar; 4) aged 18-25 years (based on Loos and Yeo 
(2014) that the relationship between the FTO gene and obesity is greatest in young adulthood); 5) 
not currently pregnant or breastfeeding; 6) willing to participate and sign informed consent. 
Exclusion Criteria: 1) currently pregnant and breastfeeding; 2) have a history of chronic disease; 3) 
regularly consume antioxidant supplements and/or phytopharmaceuticals; 4) currently participating 
in other research. 
 
Risks that may arise and how to overcome them: 
Potential harm to the procedure being performed is very rare. The potential that may be 
encountered is limited to conditions of infection and the formation of hematomas (blood clots due 
to needle sticks). This risk can be reduced by treatment by experienced professionals and the use of 
disposable equipment and aseptic procedures, as well as appropriately sized needles to minimize 
the occurrence of hematomas. Apart from that, there may be a danger of bacterial contamination 
from intervention foods made by researchers. This can be prevented by maintaining hygiene and 
sanitation during preparation, processing, packaging, and when providing intervention food. In 
addition, the possibility of side effects or dangers from consuming the dietary intervention provided 
is prevented by collecting data on dietary restrictions/allergies for each subject before the 
intervention is carried out. 
 
 
2. 
Research Methods (There may be more than one) √ Randomization 
 
 
√ Open labelled 
Single Blind 
Double Blinds 
Placebo 
√ Treatment controlled 
Others mentioned, 
Cross-over 
√ Parallel 
3. 
New Drug Research (Investigational New Group=IND)/New Equipment (Investigational New 
Equipment =INE)/New methods or techniques:  
√ There 
isn't any 
Ther
e are: 
IND 
Reg No. POM: 
Name: 
Sponsor: Company name: 
 
INE 
Reg No. POM: 
Name: 
Sponsor: Company name: 
 
Health 
Department 
Permit: 
There is 
No 
 
If there is, attach it 
Information About Try Ingredients: 
a. Efficacy: ─ 
b. Security: ─ 
4. 
 For Genetic Research, Indicate Whether Genetic Engineering Techniques Are Used: 
 
√ No: 
Yes, it has been reviewed Recombinant DNA Advisory Committee 
 Biosafety Committee 
5. 
This data is filled in if it concerns clinical drug 
trials 
Drugs Tested 
Companion Medicine 
a. 
Generic name: 
 
 
b. 
Trade name: 
 
 
c. 
Chemical name: 
 
 

d. 
Pharmacology class: 
 
 
e. 
Dosage form and drug strength: 
 
 
f. 
Packaging: 
 
 
g. 
Way of giving: 
 
 
h. 
Expired date: 
 
 
i. 
Batch Number: 
 
 
j. 
Analysis certificate: 
 
 
k. 
CPOB Certificate: 
 
 
l. 
Type and quantity of medicines to be 
imported: 
 
 
m. 
Manufacturer's name and address: 
 
 
n. 
Importer name and address: 
 
 
o. 
Distribution status of the test drug in 
other countries (if any, please attach 
it) 
 
 
p. 
Clinical trial phase: Phase I Phase II Phase III Phase IV 
6. 
How to Get Research 
Subjects: 
Individual contacts √ Basic data from other studies 
ReferenceAdvertisement (attach)Others, explain 
7. 
Subject Criteria: 
Prone to 
 
 
Child's age < 12 years 
Prisoner 
People with impaired cognitive function/unconsciousness 
Pregnant mother 
TNI and Police 
Others, please specify: ................................................ ... 
√ Not Vulnerable 
 
8. 
If this research is a clinical trial using human subjects, have pre-clinical trials/tests on animals been 
carried out, data on safety and efficacy from previous studies/in other countries)? √ NoYes 
References (Name, Title, Journal): ─ 
Resume of Research Results: ─ 
 
Previous experience (own or others) of the action to be carried out (have clinical trials on humans 
been carried out, safety and efficacy data from previous studies/in other countries): √ NoYes 
References (Name, Title, Journal): Di Renzo L, Cioccoloni G, Falco S, Abenavoli L, Moia A, Sinibaldi 
Salimei P, De Lorenzo A. 2018. Influence of FTO rs9939609 and Mediterranean diet on body 
composition and weight loss: A randomised clinical trial NCT01890070 NCT. J Transl Med. 16(1):1–
12. doi:10.1186/s12967-018-1680-7. 
Resume of Research Results: Randomized clinical trial examining the effects of FTO rs9939609 and 
the Mediterranean diet on body composition and weight loss. The results obtained show that the 
Mediterranean Diet is proven to be good for reducing body fat mass, while the data on the effects 
of FTO are still uncertain. 
 
9. 
Clinical Trial Process 
a) Intervention administration (dose regimen, invasive and non-invasive procedures, comparison 
drugs, placebo): 
Following informed consent and initial screening, blood samples will be collected from all 
research participants to establish baseline data. Subsequently, randomization of the samples will 

be conducted using the block randomization method, based on the FTO gene allele. This process 
will involve two sample randomization blocks: one for A carriers allele and another for T 
homozygous individuals. Each block will then be randomized and divided into two groups, 
maintaining a 1:1 ratio between control and dietary intervention. Following randomization, four 
groups will be formed: two groups receiving the Balanced Nutrition Diet intervention (DAC: A 
allele carriers + Diet; and DTH: homozygous T allele + Diet), and two control groups (CAC: A allele 
carriers; and CTH: homozygous T allele). Nutrition education will be provided to all groups. The 
intervention period will span 4 weeks (28 days), after which a second blood draw will be 
conducted to gather endline data. 
The Balanced Nutrition Diet is meticulously designed to supply the body with nutrients in 
suitable types and quantities, adhering to the principles of food diversity which include variety, 
balanced proportions, correct amounts, and consistency. Additionally, it emphasizes the "Fill My 
Plate" guideline, advocating for the consumption of all five food groups daily or at each meal. 
Portion sizes of the Balanced Nutrition Diet are structured according to the "Balanced Nutrition 
Tumpeng" model, encompassing 3-4 portions/day of carbohydrates, 2-3 servings/day of fruit, 3-
4 servings/day of vegetables, and 2-4 servings/day of side dishes, with restrictions set at 4 
tablespoons of sugar, 1 teaspoon of salt, and 5 tablespoons of oil per day, alongside a 
recommendation of drinking 8 glasses of water daily. 
During the intervention period, food is provided three times a day - breakfast, lunch, and 
dinner - following a 28-day menu cycle. The researcher bears the sole responsibility for covering 
the cost of all food provided to the intervention group during this 28-day period. The Balanced 
Nutrition Diet offered adheres to specific macronutrient distribution ratios of 45-55% 
carbohydrates, 15-20% protein, and 20-25% fat, as outlined by Almatsier (2010). Complex 
carbohydrates, such as whole grains, are prioritized, while protein sources lean towards low-fat 
options, with half derived from plant-based sources. Monounsaturated and polyunsaturated fats 
are favored, and organic ingredients are preferred whenever possible. 
Each meal's composition adheres to the "Fill My Plate" principle, and daily portions follow 
the "Balanced Nutrition Tumpeng" concept. Specifically, the diet provided by Eat & Fit Catering 
adheres to certain guidelines, including cooking methods that eschew fire and oil frying in favor 
of boiling, sautéing, or roasting techniques. Canola oil is the preferred oil, sodium-reduced salt is 
utilized, and mushroom stock serves as the primary flavouring agent, ensuring both healthfulness 
and taste. For each subject, energy requirements were calculated according to resting energy 
expenditure (REE) estimates using Mifflin-St. Jeor Equation (Mifflin et al. 1990). REE is then 
multiplied by the physical activity level (PAL) according to WHO-FAO that has been obtained. 
REE (women)= (9.99 x Body Weight) + (6.25 x Height) + (5 x Age) – 161 
The dietary distribution to subjects occurs three times, facilitated by couriers from the 
catering party. Should the delivery fall beyond the catering courier's radius, online delivery 
services will be utilized, with costs borne by the researcher. 
In contrast, the control group subjects do not adhere to a specific diet regimen. However, 
they will receive general guidance on healthy eating habits and will be monitored closely. 
Nonetheless, their energy requirements will still be assessed based on REE and physical activity 
levels, as previously mentioned. 
 
b) Determination of outcome indicators:  
Evidence shows that compared with TT wild type, the risk allele A FTO rs9939609 showed 
significantly higher body weight, body mass index, waist circumference, hip circumference, and 
waist-to-hip ratio (Mangge et al. 2011; Tupikowska-Marzec et al. al. 2019; Mehrdad et al. 
According to Chrostowska et al. (2013), evidence is growing that the waist-hip circumference ratio 
is a stronger indicator of cardiovascular disease than body mass index. The meta-analysis of 
Gholamalizadeh et al. (2020), showed that carriers of the A allele of the FTO rs9939609 
polymorphism had a higher fat percentage. The research results of Dorling et al. (2021) showed 

the FTO SNP rs9939609 was associated with changes in REE adjusted for fat mass and lean mass, 
with the AA allele showing a decrease compared to TT. 
Several studies have been conducted looking at the relationship between the FTO 
rs9939609 genotype and interleukin-6 (IL-6) levels, but only a few have shown real differences 
(de Luis et al. 2012b; Zimmermann et al. 2011; de Luis et al. 2016; Magno et al. al. 2018; Hosseini 
et al. Studies have also been conducted that there is an association of FTO rs9939609 with higher 
levels of C reactive protein (CRP) (Fisher et al. 2009; Sun et al. 2010; Lappalainen et al. 2011; 
Tupikowska-Marzec et al. 2019). However, other studies show contradictions (Zimmermann et al. 
2011). 
Research by Mehrdad et al. (2020a) showed that subjects with A allele carriers (AA and AT) 
had lower adiponectin levels than wild-type subjects (homozygous TT) with homozygous AA allele 
types having the lowest values although not significantly different. Several other studies also show 
the same thing in both obese and other types of adult subjects (Saucedo et al. 2017; Isgin-Atici et 
al. 2021). However, research by de Luis et al. (2016) and Duicu et al. (2016) showed a contrast, 
namely that adiponectin levels were lower in the TT genotype group compared to the AA 
genotype group. Based on what has been explained above, several outcome indicators that will 
be analyzed are waist-hip circumference, mass and total fat percentage &visceral, interleukin-6 
levels, hs-CRP levels, and adiponectin levels. 
 
Statistical analysis 
The data obtained were tested statistically using SPSS statistical software for Windows (IBM 
version 26.0, SPSS Inc., Chicago, III., USA). The normality of variable distribution was verified with the 
Shapiro-Wilk test. Analysis of Variance (ANOVA) was used for all baseline data. Paired samples t-test 
was used to see changes in calorie intake, macronutrients, BW, BMI, waist circumference, hip 
circumference, waist-hip ratio, RM, percent total fat, visceral fat, subcutaneous fat, skeletal muscle, 
IL-6, hs-CRP, and adiponectin between before and after intervention. Data are presented as mean ± 
SD and P ˂ 0.05 was considered statistically significant. 
 
c) Planned interim analysis: There is no interim analysis in this study. 
 
d) Clinical trial termination procedures: Referring to the guidelines for good clinical trials in Indonesia 
(POM RI 2016), clinical trials are terminated if clinical trial safety problems occur, such as serious 
undesirable events and serious side effects of the test product. The principal investigator will 
report the KTDS to the ethics committee no later than 3 days after the incident is discovered. The 
possibility of KTDS that could occur in this study is that the patient requires hospital treatment as 
a result of the intervention process. 
 
e) Estimated research time required for one subject per procedure: ±4 weeks 
f) Ethical issues (state your opinion about the ethical issues this research may encounter): 
• 
Respect for person (respect for human dignity): 
Subjects in this study took part based on their own conscious choice, there was no element 
of coercion. 
Subjects have the right to be protected, including that all Subject data will be kept 
confidential. 
• 
Beneficence(beneficial) Non-maleficence (not harmful): 
This research optimizes benefits and minimizes harm to subjects. 
The results of the research will be useful for society. 
The research design has been made as clear as possible. 
Researchers have competencies that are appropriate to the research topic to be conducted. 
• 
Justice(justice): 
Subjects are treated the same/or there is no differentiation between subjects. 

There is no conflict of interest 
10. 
Adverse Event reporting plan(AE) 
a. Recording (What will be reported): Each incident must be recorded in detail regarding the time 
it occurred and the causes to avoid similar incidents and as additional data for research progress 
reports. 
b. Analysis and action procedure: 
1. Anthropometric Measurements 
After an overnight fast for 12 hours, all subjects underwent anthropometric evaluation. All 
individuals were instructed to remove their shoes and wear as light clothing as possible before 
undergoing measurements. Body weight, mass & percent body fat were measured with a 
Bioelectrical Impedance Analyzer (BIA). Body height was evaluated using a stadiometer to the 
nearest 0.1 cm. BMI is calculated using the formula = body weight/height2 (kg/m2). Waist 
circumference and hip circumference were assessed using a flexible steel metric tape to the 
nearest 0.5 cm. The waist-to-hip ratio (WHR) was analyzed and evaluated according to clinical 
risk thresholds, equivalent to WHR > 0.9 for men and WHR > 0.85 for women. 
 
2. Blood Sample Analysis 
A venous blood sample of around 6-10 cc is taken using a sterile syringe by competent 
licensed medical personnel. The blood is then divided into two different sterile tubes 
(Vacutainer®). The first tube is a purple cap tube containing EDTA, while the second tube is a 
yellow cap tube containing separator gel. After that, the sample is put on ice to be immediately 
taken to the testing site. The samples in the purple tube will then be processed for DNA and RNA 
isolation. DNA isolates were used for analysis of FTO gene variants using PCR and sequencing. 
Blood samples in yellow tubes were used for analysis of serum levels of interleukin-6, hs-CRP, 
and adiponectin using the ELISA method. All blood analyzes will be carried out at the Molecular 
Genetics Laboratory, FK UNPAD. The remaining samples were stored at −80 °C to be retested if 
necessary. 
 
c. Emergency request system: Each subject will be given a contact for researchers and doctors who 
can be contacted if there are complaints of illness related to the intervention. Researchers and 
doctors can be contacted 24 hours during the research period regarding interventions for 
emergency response preparedness. If there is an emergency, the subject will be taken to the 
emergency room at Hasan Sadikin Hospital. 
 
d. Termination of subjects in research due to adverse events: If an undesirable event occurs, it must 
be immediately reported to the researcher. Researchers will then coordinate with parties who 
feel it is necessary to carry out follow-up as soon as possible. Then the researcher will assess 
whether the subject needs to be discontinued in the study after consulting with a clinical trial 
expert. 
11. 
If this research uses human subjects, are the costs of dealing with side effects the responsibility of 
this research?No √ Yes 
 
- If yes, post-research responsibilities (capacity building, benefits to local community, 
continuation of therapy on the subject, etc.) 
- Is the subject insured? √ NoYes 
If "yes" please state the insurance institution: ─ 
Duration of Insurance and/or responsibility of the researcher towards the subject? ─ 
 
12. 
If we use biological samples, will they be sent overseas? √ No Yes, please state the destination 
country and attach itdraftsMaterial Transfer Agreement (MTA)!  
 
 

 
C. 
 
Process of Obtaining Approval After Explanation (INFORMED CONSENT)/Informed Consent (IC) 
1. 
To Whom INFORMED CONSENT Is 
Explained(There may be more than 
one answer):  
Individual 
√ Group 
Guardian 
2. 
a. 
Who explains? 
Principal Researcher 
b. 
When will it be explained? 
Before INFORMED CONSENT 
screening and signing is carried out 
c. 
Are subjects given enough time to make a decision? 
Yes 
d. 
Who signed the INFORMED CONSENT? 
The prospective subject itself 
e. 
Who witnessed the INFORMED CONSENT signing? 
Research assistant 
(doctor/nurse/midwife/nutritionist
) 
3. 
Ethical problems that the subject may face 
a. 
Research risks 
 
1. Disrupts routine health service activities 
Yes 
√ No 
 
2. Causes side effects on the subject 
Yes 
√ No 
 
3. Contrary to norms and customs 
local 
Yes 
√ No 
 
4. Economic losses and stigmatization occur 
 subject 
Yes 
√ No 
b. 
Benefits of taking part 
 
 
 
1. New knowledge increases 
√ Yes 
No 
 
2. Get health services 
√ Yes 
No 
 
3. Incentives 
 
CashNo 
√ Goods/Souvenirs 
4. Compensation 
Insurance √ Cash 
NoEtc 
c. 
Excessive influence (coercion) 
 
 
 
1. Relationship between Chief Researcher and subject 
√ No 
There is 
 
2. If there 
is: 
Doctor-patient 
Teacher/lecturer- 
pupils/students 
Superiors and 
subordinates 
Etc 
d. 
• If the study uses healthy people, explain how the health checks will be carried out: ─ 
 
• If the study uses sick people, explain how to diagnose and name the doctor responsible!  
This study used young adult female subjects who were obese. The diagnosis of obesity 
is assessed by a nutritionist based on the percentage of total body fat ˃ 35%. 
Responsible doctor: dr. Lucky Angkawijaya Roring, M.Pd., AIFO. (08112228197). 
 
D. 
 
Fill in the Consent Information After Explanation (INFORMED CONSENT)/Informed Consent (IC) 
1. 
Is the Narrative in Agreement After the Subject Explanation Explaining About: 
a. Research summary information 
√ Yes 
No 
b. The treatment applied to the subject 
√ Yes 
No 
Not Available 
c. Benefits for the subject 
√ Yes 
No 
Not Available 
d. Potential danger 
√ Yes 
No 
Not Available 
e. Right to resign 
√ Yes 
No 
Not Available 
f. Incentives for subjects 
√ Yes 
No 
Not Available 
g. Type of incentives provided 
√ Yes 
No 
Not Available 
h. Compensation for subjects 
√ Yes 
No 
Not Available 

2. 
Specimen Collection (Statements 2b-2d are filled in if the answer to 2a is "yes" and 2f-2g if the 
answer to 2e is "yes") 
a. Was a specimen taken from the subject? 
No 
√ Yes, Blood 
b. Is there information on the number of specimens taken? 
√ Yes 
No 
c. Is there any information about the frequency of collection? √ Yes 
No 
d. Is there any information about how to collect it? 
√ Yes 
No 
e. Was there any invasive procedure on the subject? 
√ No 
Yes, Name it 
f. Is there any information about the potential risks of 
taking? 
√ Yes 
No 
g. Is there information about how to handle risk-taking? 
√ Yes 
No 
3. 
Subject Confidentiality 
a. Is there any information about subject 
confidentiality? 
√ Yes 
No 
b. Is there any information about specimen 
confidentiality? 
√ Yes 
No 
c. Is there any information about data confidentiality? 
√ Yes 
No 
4. 
Contact person local for respondents, please specify: Putri Novitasari (08112227291) 
Contact person centre for respondents, please specify: Putri Novitasari (08112227291) 
 
E. 
 
Statement 
1. 
Has the head of research been involved/punished for criminal/disciplinary action by the public or a 
private medical organization/an authorized body? 
√ NoYes, explain 
2. 
How long will research data be kept by the Principal Researcher? 1 to 2 years after the research is 
completed 
3. 
What precautions are taken to maintain the confidentiality of health data?  
√ 
Research documents/files will be stored in a secure location and can only be accessed by 
officers involved in the research 
√  
Computer data is only intended for officers involved in research and can be accessed using 
passwords and personal access 
 
√  
Before accessing any research-related information, personnel must sign a consent form to 
protect the security and confidentiality of the subject's health information 
√  
Before opening research files, officers must sign an agreement to maintain the confidentiality 
of the documents 
√ 
Where possible, identification of research subjects is removed (anonymous) from information 
related to research 
  
Others, explain 
4. 
I will be responsible for filling out this form and will carry it out in accordance with the proposed 
research proposal and in accordance with the principles of research ethics. 
 
 
 
 

 
Bogor, 05 June 2023 
Know, 
 
Ka. Department/Prodi Main Researcher, 
 
 
 
 
 
 
 
Dr. Drs. Forester 
 
Putri Novitasari, S.Gz., M.Sc 
 
 
 
 
Supervisor I, Supervisor II, 
 
 
 
 
 
 
 
 
Dr. Drs. Forester 
 
Prof. Dr. Ir. Hardinsyah, MS 
 
 
 
Supervisor III 
 
 
 
 
 
 
Prof. Dr. Ir. Hadi Riyadi, MS 
 
 

 
INFORMATION SHEET 
 
The Effect of a Balanced Nutritional Diet on Cardiovascular Risk Factors Among Two Types of FTO Gene 
rs9939609 ini Obese Young Women 
 
I am Putri Novitasari, a Doctoral (S3) student in Nutrition Science from the IPB University who is conducting 
research for her dissertation. I invite you to participate in this research, your participation in this research is 
voluntary, so you can decide whether to participate or not. 
 
Research purposes: 
The general aim of this research is to 
Examining the Effect of a Balanced Nutritional Diet on Cardiovascular Risk Factors Among Two Types of FTO 
Gene rs9939609 in Obese Young Women. 
 
Meanwhile, the specific aim of this research is to 
1. Analyze differences in the body composition of obese young women between A allele carriers (AC) and TT 
allele homozygous (TH) groups after Balanced Nutrition Diet intervention 
2. Analyze differences in biomarkers of inflammation related to cardiovascular risk (interleukin (IL-6), high-
sensitivity CRP (hs-CRP), and adiponectin (ADP)) of obese young women between A allele carriers (AC) 
and TT allele homozygous (TH) groups after Balanced Nutrition Diet intervention 
 
Why Subject was chosen: 
You were selected for this study because you meet all the inclusion criteria, namely: 1) Have a fat percentage 
of >35% and have light physical activity based on PAL (and have participated in preliminary research to 
completion); 2) Sundanese ethnicity; 3) normal fasting blood pressure and blood sugar; 4) aged 18-25 years 
(based on Loos and Yeo (2014) that the relationship between the FTO gene and obesity is greatest in young 
adulthood); 5) not currently pregnant or breastfeeding; 6) willing to participate and sign informed consent. 
 
Procedures/Procedures: 
You will be invited to the UPT Health Services, Indonesian Education University gathered with other 
respondents at one time. First of all, an explanation of the aims and objectives of the research is provided, 
followed by an explanation of the actions/treatment that will be carried out in this research including the 
benefits and disadvantages of being a research subject including the compensation you will receive and the 
right to withdraw from the research. Then there will be a distribution of informed consent and if the 
prospective subject is willing and signs the informed consent and passes the screening, they will officially 
become research subjects. 
The first stage of screening is assessment, physical examination (blood pressure, pulse and fasting blood 
sugar), and anthropometry (body weight, height, waist circumference and hip circumference, total & 
abdominal fat mass and percentage) as basic measurements for internal screening All prospective subjects 
had fasted overnight. If you do not pass the screening, then you will be declared disqualified. On the other 
hand, if you pass the screening then you are declared a research subject. Medical assessments including 
blood pressure and blood sugar checks by nurses/midwives and health checks by doctors are evaluated 
before and after the intervention. 

Screening of potential subjects, signing of the INFORMED CONSENT, collection of subject blood specimens, 
and data collection were carried out at the UPT Health Services (Poliklinik), Indonesian Education University. 
Address: Jl. Dr. Setiabudhi No. 229, Isola, Sukasari, Bandung City 
After that, on the same day, you will have a blood sample taken as initial biochemical data. After the initial 
biochemical data was obtained, samples were randomized using the block randomization method based on 
the FTO gene allele. There will be 2 sample randomization blocks, namely the A carriers allele block, and the 
T homozygous block. Each block was randomized and divided into 2 groups with a ratio of control to dietary 
intervention (1:1). Because this research uses a parallel design, you only experience one type of intervention. 
Randomization was carried out using a roll of paper containing subject codes without replacement. 
Randomization was carried out by personnel who did not participate in research activities. After that, they 
enter the intervention stage for 4 weeks (28 days) according to the group. After 4 weeks (28 days), a second 
blood draw will be taken as final biochemical data. Analysis of the FTO gene and other blood biochemistry 
will be carried out at the Molecular Genetics Laboratory, Faculty of Medicine, Padjadjaran University. 
Height measurement uses a microtome with an accuracy of 0.1 cm, BB measurement uses a step scale with 
an accuracy of 0.1 kg. Waist circumference and hip circumference were measured using a body 
circumference meter with an accuracy of 0.1 cm. Mass and percentage of total & visceral fat using the 
Bioelectrical Impedance Analyzer (BIA) with an accuracy of ± 400 grams for a body weight of 0.0–40.0 kg, 
while for a body weight of 40.0–135.0 kg, the accuracy is ± 1%. Blood biochemical data include high 
sensitivity-C-reactive protein (hs-CRP); interleukin-6 (IL-6), and plasma adiponectin. Gene data examined 
includes FTO gene variations. Consumption data includes: recording food consumption (self-administered 
food record). Food records 2x24 hours were carried out before the intervention started and during the 
intervention. Subjects will be instructed to record or record the type and weight of food and drinks consumed 
and then the nutrients will be reviewed and calculated. Compliance with the consumption of a Balanced 
Nutrition Diet using Googleform which must be filled in by the intervention group every day. The minimum 
limit for subject compliance is 80% of the entire diet provided. Physical activity data includes the length of 
time doing various types of physical activity within 24 hours, used to estimate the subject's energy 
expenditure. 
Food was provided during the intervention period 3 (three) times each day, namely breakfast, lunch and 
dinner. The food menu uses a 28-day menu cycle. The cost of all food provided to the intervention group 
during the 28 days was the sole responsibility of the researcher. 
The characteristics of the Balanced Nutrition Diet that will be provided have a distribution of the composition 
of the macronutrients that will be intervened in are as follows: 45-55% carbohydrates, 15-20% protein, and 
20-25% fat (Ministry of Health 2014). The type of diet and portions that will be given are the same for each 
feeding unless there are certain food restrictions or allergies, the type of food will be adjusted specifically to 
that individual. The calories that will be given range from 300-400 Cal for breakfast, 400-500 Cal for lunch, 
and 300-500 Cal for dinner. 
The choice of carbohydrates should be varied and should be complex carbohydrates such as whole grains. 
The choice of protein type is prioritized from low-fat protein sources and half of it is vegetable protein. The 
choice of type of fat is prioritized in the form of monounsaturated and polyunsaturated fats. If possible, food 
ingredients should be prioritized in the form of organic food. The composition of each meal refers to the 
principle of "Fill My Plate" and the daily portion refers to the principle of "Balanced Nutrition Tumpeng". The 
characteristics of the diet that will be provided specifically from the Eat & Fit Catering diet consist of 1) 
Cooking methods that use boiling/sautéing/roasting techniques without fire and avoiding frying techniques 

with oil; 2) The oil used is canola oil; 3) The salt used is a special type of salt which has less sodium content; 
4) The flavouring used is mushroom stock. 
For each subject, energy requirements were calculated according to resting energy expenditure (REE) 
estimates using Mifflin-St. Jeor Equation (Mifflin et al. 1990). REE is then multiplied by the physical activity 
level (PAL) according to WHO-FAO that has been obtained. 
REE (women)= (9.99 x Body Weight) + (6.25 x Height) + (5 x Age) – 161 
The technical distribution of diets to subjects is delivered 3 times by couriers from the catering party. If the 
delivery is outside the delivery radius of the catering courier, the food will be delivered by online delivery 
services and costs will be charged to the researcher. 
In contrast, in the control group, subjects do not follow a specific diet, but they will also receive general 
recommendations about healthy eating habits and will only be monitored, however, their energy needs will 
still be evaluated based on REE and physical activity as mentioned above. 
 
Risks and inconveniences: 
The risks in this study are very small/minimal, but there is inconvenience because your time will be taken up 
for collecting data and recording dietary compliance (for those in the intervention group). Apart from that, 
the potential that may be encountered is limited to conditions of infection and the formation of hematomas 
(blood clots due to needle sticks). This risk can be reduced by treatment by experienced professionals and 
the use of disposable equipment and aseptic procedures, as well as appropriately sized needles to minimize 
the occurrence of hematomas. Apart from that, there may be a danger of bacterial contamination from 
intervention foods made by researchers. This can be prevented by maintaining hygiene and sanitation during 
preparation, processing, packaging, and when providing intervention food. In addition, the possibility of side 
effects or dangers from consuming the dietary intervention provided is prevented by collecting data on 
dietary restrictions/allergies for each subject before the intervention is carried out. 
 
Benefits (direct to the subject and general): 
For you, you can find out the allele type of the FTO rs9939609 gene as an illustration of genes related to 
obesity and which can be used as a basis for precision nutritional interventions and will receive nutritional 
education about balanced nutrition. For the public, it is hoped that this research can increase knowledge 
about consumption recommendations, especially to normalize nutritional status and reduce the risk of 
cardiovascular disease by improving health status, especially for young adult women. 
 
Alternative procedure: 
"There isn't any" 
 
Data confidentiality: 
Researchers will guarantee the confidentiality of research data. 
 
Estimated number of subjects to be included: 

The total number of research subjects who will take part in this research is around 44 people. 
 
Volunteerism: 
Subject participation is voluntary without any coercion and is accompanied by responsibility until the 
completion of the research. 
 
Subject Participation Period: 
You will be involved in the entire series of this research for approximately 2 months, consisting of 1 month 
intervention period and an additional 2 weeks each before and after the intervention period for preparation. 
 
Subjects can be excluded/withdrawn from research: 
Drop-Out Criteria are 1) you state that you do not wish to continue; 2) indications of exclusion criteria were 
found in you during the research; 3) You did not undergo complete blood and/or other necessary tests. 
 
Possible funding from health insurance companies or researchers: 
“no insurance was provided in this study” 
 
Incentives and compensation: 
Transport costs when you go to the screening site and sign the INFORMED CONSENT will be reimbursed in 
cash amounting to IDR. 50,000,-. Those who have participated until the final data collection will be given 
incentives in the form of contact materials in the form of boxes and cutlery. 
 
Question: 
If anything is unclear or you need to ask questions, please contact the principal investigator: 
Putri Novitasari (08112227291) : D Amerta Residence Jl. Pandanus III Block E1 No. 30 Bojongsoang District, 
Bandung Regency 
Contact a doctor if any side effects occur: Dr. Lucky Angkawijaya Roring, M.Pd., AIFO 
 
 
 
 
 
 
 
 

 
APPROVAL AFTER EXPLANATION (INFORMED CONSENT) 
TO PARTICIPATE IN RESEARCH 
(INFORMED CONSENT) 
 
I have read or received an explanation, am fully aware, understand and comprehend the objectives, benefits 
and risks that may arise in the research, and have been allowed to ask questions and have been answered 
satisfactorily, and can withdraw from participation at any time. then I agree/disagree*) take part in this 
research, entitled: 
 
The Effect of a Balanced Nutritional Diet on Cardiovascular Risk Factors Among Two Types of FTO Gene 
rs9939609 in Obese Young Women 
 
I voluntarily chose to take part in this research without pressure/coercion from anyone. I will be given a copy 
of the explanation sheet and the signed consent form for my records. 
I agree: 
Yes No*)   
 
 
Date: 
 
Signature (if not available, 
thumbprint can be used) 
Participant Name: 
Age: 
Address: 
 
 
Researcher Name: 
  
 
 
Witness Name: 
 
 
 
 
*) cross the unnecessary ones 
 
 
 
 
 
 
 
 
 
 
 

CASE REPORT FORM 
 
Case Report Form is available at:https://forms.gle/zsCVMFcFvAzZJ6HcA