Organic Diet and Children's Health - ORGANIKO LIFE+
Phase: NA
Conditions: Oxidative Stress, Inflammation
Sponsor: Cyprus University of Technology

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Protocol 
Organic Diet Intervention in Primary School Children 
(ORGANIKO)    
                                                           
NCT02998203 
 
11-8-2016 
 

1 
 
Study Protocol 
CONSORT Checklist of Items for Reporting Cluster Randomized Trials of NPTs 
 
A cluster-randomized crossover trial of organic diet for primary school children 
Konstantinos C. Makris1*, PhD, Corina Konstantinou1, MS, Xanthi D. Andrianou1, 
MS, Pantelis Charisiadis1, PhD, Alexis Kyriacou2, RD, Matthew O. Gribble3,4^, PhD 
DABT, and Costas A. Christophi1^, PhD 
1 Cyprus International Institute for Environmental and Public Health, Cyprus 
University of Technology, Limassol, Cyprus 
2 Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK 
3 Department of Environmental Health, Emory University, Atlanta, GA, USA 
4 Department of Epidemiology, Emory University, Atlanta, GA, USA 
 
 
^ Both authors contributed equally to this work. 
 
 
 
 
 
* Corresponding author: Konstantinos Christos Makris, Associate Professor of 
Environmental Health, Cyprus International Institute for Environmental and Public 
Health, School of Health Sciences, Cyprus University of Technology, Irinis 95, 
Limassol, Cyprus.  
Phone: 357-25002398, FAX: 357-25002676  
E-mail: konstantinos.makris@cut.ac.cy (KCM) 
 
 
 
 
 

2 
 
CONSORT Checklist of Items for Reporting Cluster Randomized Trials of 
NPTs  
Section 
Item 
CONSORT Description 
Extension for NPT 
Trials & cluster 
randomised trials1,2  
 
Title and abstract 
 
 
1a 
Identification as a 
randomized trial in the title 
 
 
 
1b 
Structured summary of trial 
design, methods, results, and 
conclusions  
Refer to CONSORT 
extension for abstracts 
for NPT trials 
 
The title is A cluster-randomized crossover trial of organic diet for primary school 
children. The abstract can be found at the beginning of the manuscript.  
Introduction 
Background and 
Objectives 
2a 
Scientific background and 
explanation of rationale 
Rationale for using a 
cluster design 
 
 
Specific objectives or 
hypotheses 
Whether objectives pertain 
to the cluster level, the 
individual participant level 
or both 
The background and objectives are described at the “Introduction” section of the 
manuscript. 
The rationale of using a cluster design is described in the Methods part below (Item 
3a). 
Methods 
 
 
 
 
Trial design 
3a 
Description of trial design 
(such as parallel, factorial) 
including allocation ratio 
When applicable, how 
care providers were 
allocated to each trial 
group 

3 
 
 
3b 
Important changes to 
methods after trial 
commencement (such as 
eligibility criteria), with 
reasons 
Definition of cluster 
and description of how 
the design features 
apply to the clusters: 
A 2 x 2 cluster-randomized cross-over trial at subject level was conducted to evaluate 
the effect of a 40-day organic diet compared to a 40-day conventional diet on 
biomarkers of exposure (pesticides metabolites) and biomarkers of effect (oxidative 
stress/inflammation markers) in children. The study was conducted in six randomly 
selected primary schools (clusters) with two periods (organic and conventional) in 
Limassol, Cyprus between January and April 2017. The trial was approved by the 
Cyprus National Bioethics Committee (ΕΕΒΚ/ΕΠ/2016/25) and the Cyprus Ministry 
of Education and Culture (7.15.06.15/2). The schools were a priori randomized to one 
of two groups differing only on the sequence of the treatments; organic diet -
conventional diet (Group 1) and conventional diet-organic diet (Group 2). The ratio of 
Group 1: Group 2 participants was 1:2.5. 
The reasons for this cluster randomization were: (1) to avoid the transfer of knowledge 
within schools about the organic diet intervention from children randomised in the 
intervention arm to children randomised in the conventional arm (contamination 
effect); (2) to enhance compliance, since all participating children at a given school 
would follow the same intervention; (3) more efficient delivery of the organic meals 
during the organic period since the organic meals-preparing restaurant would daily 
deliver meals to 3 instead of 6 schools.  

4 
 
The reasons for the crossover design were: (1) each participant serves as his/her own 
control and the influence of confounding variables (i.e., variables that are imbalanced 
between the treatment and control groups) is reduced; (2) repeated measures over a 
longitudinal study reduce the chance for a study finding to be attributable to chance 
under temporal measurement error. One organic-certified restaurant was responsible 
for the preparation and provision of organic meals for all schools during the organic 
period helping ensure that the treatment was comparable per the stable unit treatment 
value assumption (SUTVA) allowing us to draw meaningful inference about the effect 
of organic diet. Informed consent was obtained at school level by the headmaster of 
the participating school, followed by written informed consent that was obtained from 
each participating children’s parents or legal guardians. 
Participants 
4a 
Eligibility criteria for 
participants  
When applicable, 
eligibility criteria for 
centers and those 
performing the 
interventions 
Eligibility criteria for 
clusters 
 
4b 
Settings and locations where 
the data were collected 

5 
 
Eligibility criteria for schools and participants 
The following eligibility criteria were set for the clusters (schools): i) being a public 
primary school in the district of Limassol, Cyprus, and ii) being located within the 
urban area of Limassol. Following the bioethics approval of the study, 12 primary 
schools’ headmasters were randomly selected and contacted by the research team’s 
coordinator. Six schools accepted to implement the study. Eligible participants were 
healthy children attending any of the six selected primary schools with ages of 10 to 
12 years old, residing in Cyprus, at least for the last five years, and systematically 
consuming conventional food (>80% of the week’s meals). Exclusion criteria included 
children with chronic conditions (e.g. diabetes, asthma) or allergies in food (e.g. 
gluten, lactose tolerance). 
Recruitment process, setting for data collection 
Informational flyers were offered to parents and information meetings were arranged 
to present study-relevant details and to provide study materials for the parents’ review 
(menus, details of study, forms of interest, consent forms for the parents/guardians of 
the participating child, and forms for breakfast and afternoon snack options). Parents 
that could not attend the meeting received the relevant material at home through the 
schools. Similar meetings, although using different study materials, were arranged 
with children in each of the six selected schools to inform them about the study, to 
explain to them the definition of organic food products (raw and processed), and to 
have them taste organic fruits. The importance of compliance to the study protocol 
was highlighted to both parents and children and the ways to report it in a diary, 
including examples of proper use. The research team checked if all eligibility criteria 
were satisfied, using the completed interest forms, and parents were accordingly 
informed via telephone. Following, informed consents were signed by parents of the 
children that were willing to participate. For eligible participants, a baseline 
questionnaire was administered to parents via telephone. Bags containing six coded 
urine vials, sampling dates, instructions for urine collection, and the food diary were 
given to children or to their parents during school hours. The organic restaurant was 
selected based on a public tender procurement procedure with some of the 
requirements being the use of 100% certified organic raw materials and food products, 
frequently renewed certificate for preparation of organic meals, and national 

6 
 
accreditation for delivery of meals to schools, complying to ISO 22000 and HACCP 
protocols. 
 
Interventions
† 
5 
The interventions for each 
group with sufficient details 
to 
allow 
replication, 
including how and when 
they 
were 
actually 
administered 
Precise details of both 
the experimental 
treatment and 
comparator  
Whether interventions 
pertain to the cluster 
level, the individual 
participant level, or both 

7 
 
Each school that participated in the study was a priori randomized to one of the two 
groups depending on the sequence of the treatments; organic-conventional (Group 1) 
and conventional-organic (Group 2). The order in which participants undertook the 
organic and conventional periods of the study depended on their school, hence the 
intervention randomization pertained to the cluster/school level. Schools in Group 1 
began first with the organic period and continued with the conventional period 
whereas schools in Group 2 began first with the conventional period and then switched 
to the organic period. During the conventional period, participants were asked to 
maintain their usual dietary habits and choices (>80% conventional diet) for a total of 
maximum 40 days. The organic period was organized in two 20-day cycles with 
differences in the menu to allow for greater variety in the meals, so that the 
participants’ compliance to the organic treatment would be enhanced. During the 
organic period, participants were asked to strictly follow the two 20-day organic 
dietary menus provided to them for a total of 40 days. The organic dietary menus were 
prepared by a certified dietitian based on EFSA energy requirements for children aged 
10-12 years,3 and included five meals per day; breakfast, morning snack, lunch, 
afternoon snack, and dinner. The meals of the organic period were delivered to schools 
Monday to Saturday, except for Sunday. Upon arrival of daily meals to each school, 
the teachers and headmaster were responsible for handing the packages to each 
participating child, using a project participant list around lunch time. On Saturday, the 
food package included both the Saturday and Sunday meals; for the Sunday meals, the 
foods were raw so that the parents would cook them fresh on Sunday. The meals of 
lunch and dinner were the same for all participants. For the breakfast, morning and 
afternoon snacks, children could choose based on a list of available products before 
the beginning of the organic period. Participants crossed over to the alternate diet on 
the following day after the first period was completed. A washout period was not 
required; it was intrinsically included in the two periods, since the first urine sample of 
the second period was collected about 12 days after the beginning of the second period 
and the pesticides half-lives are short (half-life for pyrethroids is less than 12 h and 
those for neonics range from 5-33 hours), so no carryover effect was expected.4,5  
 

8 
 
Each participant provided maximum six first morning urine samples during the whole 
duration of the 2-period study; one baseline sample, two samples in the conventional 
period, and three samples in the organic period (Fig.1). Anthropometric measurements 
(weight, height, and waist circumference) were taken at the beginning of the study, at 
the end of the organic period, and at the end of the study (for Group 2, the end of study 
and end of organic period was the same time point) by trained researchers at the school 
premises.6 A baseline questionnaire was administered to parents at the beginning of 
the study through a telephone interview to collect information on demographic 
characteristics the child’s lifestyle/behaviour habits, and possible non-dietary pesticide 
exposure sources. A food frequency questionnaire was administered to the parents at 
the end of the conventional period through a telephone interview to collect information 
about the food habits of the children during the conventional period. A food diary was 
provided to the parents at the beginning of the study and parents completed it during 
the organic period, in order to collect information about the compliance of the children 
to the organic dietary menu. 
 
5a 
 
Description of the different 
components of the interventions 
and, when applicable, 
descriptions of the procedure for 
tailoring the interventions to 
individual participants 
Reported in item 5 
 
5b 
 
Details of whether and how the 
interventions were standardized. 

9 
 
The organic diet intervention was standardized as a single restaurant was the only 
certified provider of the organic meals for the participants. Moreover, we attempted to 
standardize the organic meals using two indicative 20-day dietary menus that were 
prepared by a registered dietitian based on the average energy requirements of children 
10-12 years old. However, because children may have different needs based on their 
activity level and metabolism, parents were advised to complement their children’s 
diet with certified organic products, if it was deemed necessary, and that their children 
shouldn’t be forced to consume the total quantity of their organic meals, if they were 
satisfied with a smaller portion. In the case that any deviations from the organic menu 
(consumption of conventional food items during a party, school event, societal event, 
etc.) occurred, parents were a priori advised to simply note it in the food diary. In 
cases of absence from school (e.g. for health reasons, flue, etc.), the parents were 
responsible to pick up the meals from school, note in the diary the days of absence and 
self-report the medical reason of absence. If the child couldn’t eat the organic food 
because he/she was sick, then the parents would also note that in the diary if other 
foods were consumed (for example soup). In case that children/parents forgot to pick 
up the organic meals from their schools, the school would inform a member of the 
research team. The research team member had access to the contact details of the 
participants and would call them to arrange the pick-up of the organic food.   
 
5c 
 
Details of whether and how 
adherence of care providers to 
the protocol was assessed or 
enhanced 

10 
 
Since there was only one provider of organic meals to schools, the same raw organic 
materials/ingredients and products, preparation of meals, and delivery of organic 
packages were applied to all participants. The research team was in close 
communication with the organic meal provider and delivery team to ensure that the 
meals preparation and menu options for each day were strictly followed based on the 
20-day organic menu cycle. The research team was conducting frequent checks in 
school during meal delivery hours and during organic meal hand out to participants to 
ensure adherence to the menu. The team had also weekly visits to each school to 
interact with student participants asking their opinion on the food choices and the 
menu quality. Children and parents opinions about the menu were routed back to the 
organic restaurant to enhance the adherence of the menu protocol to the participant 
needs. The participants’ parents were given access to a hotline that was referring them 
to the trained researcher for communicating any issues with their meals; the research 
team was in daily communication with the restaurant ensuring that a full cycle of 
quality control and participant opinions were feeding back into the standardised 
protocol of the organic period. 
 
5d 
 
 
Details of whether and how 
adherence of participants to 
interventions was assessed or 
enhanced 
The adherence of participants to the organic diet intervention was assessed with a food 
diary in which parents were instructed to record any exceptions to the organic diet. 
Moreover, the diary was used to note any sickness and any pesticide use at home. The 
frequent telephone communication with parents, the weekly visits at schools, and the 
daily communication with the restaurant were key factors that further enhanced the 
compliance to the organic diet treatment. In order to encourage adherence to the 
organic diet until the end of the period, a public event was organized during the mid-
period of the study with activities for the participating children and free sampling of 
organic food products. 
 

11 
 
Outcomes 
6a 
Completely defined 
pre-specified primary 
and secondary 
outcome measures, 
including how and 
when they were 
assessed 
Whether outcome measures 
pertain to the cluster level, the 
individual participant level, or 
both 
 
Per the trial protocol, the primary outcomes were the biomarkers of exposure to 
pesticides using two non-specific pesticides metabolites (3-phenoxybenzoic acid (3-
PBA), 6-chloronicotinic acid (6-CN)) measured in first morning urine voids collected 
any two up to six time points (full participation of child all 80 days of the trial). The 
secondary outcomes were the biomarkers of oxidative stress/inflammation (8-iso-
prostaglandin F2a (8-iso-PGF2a), malondialdehyde (MDA) and 8-hydroxy-2′-
deoxyguanosine (8-OHdG)) measured in the same urine samples.  
In post-hoc analysis, we also reported the effect of the intervention on age and sex-
adjusted BMI standard deviation scores (SDS) using the WHO 2007 growth reference 
standard for children.7 BMI SDS were calculated based on the measurements of 
weight and height taken at the baseline and end of the organic period (two timepoints), 
adjusting for age and sex. We also reported the observational associations of 3-PBA 
with OSI biomarkers as post-hoc ancillary analyses. 
 
6b 
Any changes to trial 
outcomes after the trial 
commenced, with 
reasons 
 

12 
 
The only change that took place was the addition of the BMI SDS as a post-hoc 
outcome because of the BMI importance in often mediating associations between 
exposures to environmental stressors and metabolic outcomes. However, this was a 
post-hoc analysis since the current study design could not support the investigation of 
biological plausibility mechanisms by which the intervention could influence the 
magnitude and variability of BMI scores. Furthermore, we cannot exclude the 
possibility that the participants were consuming a different amount of calories or 
changed their habits during the organic phase as opposed to the conventional diet, as 
the current study was not designed to delivering strict isocaloric diets at the two phases 
(but participants were free to consume as much they wished). Additionally, the food 
frequency questionnaire that was used at the end of the conventional period aimed to 
capture the overall habits of the participants, and we have not recorded deviation from 
the organic diet in which extra or less organic food - compared to what was provided - 
was consumed during the organic period as all participants were advised to avoid 
disturbing usual eating habits.     
Sample size 
7 
How sample size was 
determined and, when 
applicable, explanation 
of any interim analyses 
and stopping rules 
When applicable, details of 
whether and how the 
clustering by care 
providers or centers was 
addressed  
Method of calculation, 
number of clusters(s) (and 
whether equal or unequal 
cluster sizes are assumed), 
cluster size, a coefficient of 
intracluster correlation 
(ICC or k), and an 
indication of its uncertainty 

13 
 
In order to estimate the sample size of this crossover study, the PS software for 
calculating sample size was used.8 We used the paired t test study design for 
calculating the power of this test, assuming that each subject has a pair of values (one 
for conventional and one for organic diet). The variable used for the estimation of the 
sample size was a biomarker of inflammation (C-reactive protein), because the 
biomarkers of inflammation/oxidative stress were one the primary outcomes for the 
trial and we information on pesticide levels were unavailable at that time. The lack of 
pertinent human studies with similar setting and characteristics to ours that involved 
exactly the same biomarkers of effect (8-OHdG and isoprostanes) led us to use the 
available human study of CRP.9 
The input parameters were: significance level, within patient standard deviation or 
standard deviation of the difference between the two values for the same patient, 
power and minimal detectable difference in means. Based on the literature, the within 
subject standard deviation of CRP was assumed to be 0.59 and we hypothesized a 
minimal detectable difference in biomarkers of effect (CRP) between the organic and 
conventional treatment to be 0.1, based on other intervention studies10–12. Assuming a 
power of 80% and a two-sided 5% significance level, the sample size for this two-
treatment crossover study was estimated to be 200 children. The clustering was not 
addressed, but the within cluster within period and the within cluster between period 
intra cluster correlation estimates were assumed equal.  
Randomization
– sequence 
generation† 
8 
Method used to generate the 
random allocation sequence, 
including details of any 
restriction (e.g., blocking, 
stratification) 
Details of stratification 
or matching if used 
 
Schools were randomly assigned following simple randomization procedures of no 
restriction or matching (computerized random numbers) to 1 of 2 groups (organic-
conventional or conventional-organic). 

14 
 
Allocation 
concealment 
9 
Mechanism used to implement 
the random allocation 
sequence (such as sequentially 
numbered containers), 
describing any steps taken to 
conceal the sequence until 
interventions were assigned 
 Specification that 
allocation was based 
on clusters rather than 
individuals and 
whether allocation 
concealment (if any) 
was at the cluster level, 
the individual 
participant level, or 
both 
Allocation was done at the school level rather than the individual level. The 
interventions were assigned after receiving the confirmation from the headmaster, 
before the meeting with the parents and the children. The allocation sequence could 
not be concealed from the participants since they knew when they were consuming 
their typical diet and when the organic meals. Also, the allocation sequence could not 
be concealed from the researchers enrolling the participants since they were informing 
the participants of the relevant information, such as the first day of the organic meals 
pick-up and the last day of the organic period. The allocation sequence, however, was 
concealed from the researchers performing the biomarker analysis since the urine vials 
were coded.  
Implementatio
n 
10 
Who generated the 
allocation sequence, who 
enrolled participants, and 
who assigned participants 
to interventions 
Who generated the random 
allocation sequence, who 
enrolled clusters, and who 
assigned clusters to 
interventions 
 
Simple randomization was performed by a computer generated random list that was 
prepared by an investigator with no clinical involvement in the trial. A member of the 
research team enrolled participants after knowing the allocation sequence for each 
school since parents and children should be informed of the order the intervention was 
going to take place. 

15 
 
Blinding  
11a 
 
If done, who was blinded 
after assignment to 
interventions (for example, 
participants, care providers, 
those assessing outcomes) 
and how 
If done, who was 
blinded after assignment 
to interventions (e.g., 
participants, care 
providers, those 
administering co-
interventions, those 
assessing outcomes) and 
how 
 
The blinding of the participants to group assignment was not possible, since 
participants knew which diet they were following. The blinding of the researchers to 
the subjects’ identity was achieved by the coding of all study materials (urine 
containers, questionnaires, and diaries). The study personnel who obtained the 
outcome measurements were also not informed of the group assignment. The 
personnel who delivered the intervention did not take any outcome measurements. All 
outcome assessors and data analysts were kept masked to the allocation. 
 
11b 
If relevant, description 
of the similarity of 
interventions 
 
 
Not relevant. 
 
11c 
 
If blinding was not 
possible, description of 
any attempts to limit bias 
 
Not relevant. 

16 
 
Statistical 
methods† 
12 
Statistical methods 
used to compare 
groups for primary 
outcome(s); methods 
for additional analyses, 
such as subgroup 
analyses and adjusted 
analyses 
When applicable, details 
of whether and how the 
clustering by care 
providers or centers was 
addressed 
How clustering was taken 
into account 
 
During the design phase of the study, power calculations were conducted to estimate 
the optimal sample size of a study assuming 80% power with a two-sided 5% 
significance level to detect a minimal detectable difference of 0.1 units in OSI 
biomarkers between the organic and conventional treatment, while the within subject 
standard deviation of the biomarker of effect was assumed to be 0.5. The clustering 
was not addressed, but the within cluster within period and the within cluster between 
period intra cluster correlation estimates were assumed equal.    

17 
 
Descriptive statistics were used to summarize the demographic and other 
characteristics of participating children. Categorical variables were described with 
frequencies and percentages, normally-distributed continuous variables as mean±SD 
and non-normal continuous variables as median and interquartile range (25th-75th 
percentiles). Box plots were used to visually inspect the biomarker data. For data 
below LOD, imputation was performed based on existing suggestions for handling 
non-detect data13. For 6-CN and 3-PBA, the percentage of data below LOD was 72% 
and 23% accordingly, so the imputation was performed using the regression on order 
statistics (ROS). For MDA and creatinine, the percentage of data below LOD was very 
low (≈ 1%), so the LOD/2 imputation was used. The baseline characteristics were 
compared between the study groups with t-test for the normal continuous variables or 
Wilcoxon test, and chi-square for the normal, non-normal, and for the categorical 
variables, respectively.   
The percent change between the baseline (last sample of conventional treatment before 
the start of the organic treatment) and after 40 days of organic diet (last sample of 
organic treatment) was determined with one sample t-test for all biomarkers (log-
transformed) and the change between the conventional and organic treatment 
(medians) was determined using Wilcoxon test for all biomarkers (non-normal 
variables). 

18 
 
Primary analysis of outcomes 
Linear mixed-effect regression models were used for continuous outcomes and logistic 
models for binary variables (i.e. those with >70%values below LOD), to account for 
the duration and the effect of treatment. To account for the clustering of participants 
within schools and the repeated measures within person, the models will include 
student-level and school-level random intercepts with unsupervised covariance matrix.  
Fixed effects were: the treatment condition (organic or conventional) and time (days of 
treatment, where time=0 was the start of the treatment). An interaction term for the 
treatment condition and time were considered and dropped when not meeting the 
threshold of p-value=0.05. The models were adjusted for the baseline value of the 
outcome in order to account for the background biomarker levels of the participant, 
The baseline sample was a conventional sample for both groups but it was not 
consecutive to the conventional phase due to the study design and, thus, it is indicative 
of each participants exposure prior to participation in the study  
In all regression models, the continuous variables, other than time, were centred at the 
population means.  
Post-hoc analysis 
Post-hoc ancillary analyses to help towards the interpretation of the results included: 
-Regression models that describe the association of primary outcomes with secondary 
outcomes adjusting for the baseline levels of each outcome, time, age and sex. 
-Regression models that describe the impact of organic diet on participants’ BMI SDS 
with or without conditioning on the outcomes as candidate mediators. These models 
included only participants with available anthropometric measurements before and 
after the organic treatment, hence only two timepoints for the BMI SDS and the 
biomarkers were used.  
Sensitivity analysis  
Two sets of sensitivity analyses were undertaken based on the primary analysis of the 
outcomes: 

19 
 
-Regression models that were not adjusted for the baseline value of the outcome. 
Hence, the baseline sample excluded from the analysis. 
-Regression models excluding the two participants who followed the opposite order of 
treatment compared to the group their school was allocated. 
 
Estimation of the geometric mean ratios and odds ratios 
Geometric mean ratios (GMR) of the outcomes and 95% confidence intervals (95% 
CIs) were estimated exponentiating the regression parameters from the linear mixed-
effect regression models. Odds ratios (OR) and 95% CIs were estimated 
exponentiating the regression parameters from the logistic regression models. 
Results 
Participant flow (a 
diagram is 
strongly 
recommended) 
13a 
For each group, the 
numbers of participants 
who were randomly 
assigned, received 
intended treatment, and 
were analyzed for the 
primary outcome 
For each group, the numbers 
of clusters that were 
randomly assigned, received 
intended treatment, and were 
analysed for the primary 
outcome 
 
13b 
For each group, losses and 
exclusions after 
randomization, together 
with reasons 
 
 13c 
 
For each group, the delay 
between randomization and 
the initiation of the 
intervention 

20 
 
 
ne
w 
 
Details of the experimental 
treatment and comparator as 
they were implemented 
The participant flow details and diagram are included in the “Results” section of the 
manuscript. 
Recruitment 
14a 
Dates defining the periods 
of recruitment and follow-
up 
 
 
14b 
Why the trial ended or 
was stopped 
 
The study tool place during January-April 2017. The study ended according to the 
study design. 
The dates are described in the “Methods” section of the manuscript.  
Baseline data 
15 
A table showing baseline 
demographic and clinical 
characteristics for each 
group 
When applicable, a 
description of care providers 
(case volume, qualification, 
expertise, etc.) and centers 
(volume) in each group 
 
 
 
Baseline characteristics for 
the individual and cluster 
levels as applicable for each 
group 
The table with the baseline data is included in the “Results” section of the manuscript 

21 
 
Numbers analysed 
 
 
16 
For each group, number of 
participants (denominator) 
included in each analysis 
and whether the analysis 
was by original assigned 
groups 
For each group, number of 
clusters included in each 
analysis 
The numbers analysed are described in the “Results” section of the manuscript. 
Outcomes and 
estimation 
17a 
For each primary and 
secondary outcome, 
results for each group, and 
the estimated effect size 
and its precision (such as 
95% confidence interval) 
Results at the individual or 
cluster level as applicable and 
a coefficient of intracluster 
correlation (ICC or k) for 
each primary outcome 
 
17b 
For binary outcomes, 
presentation of both 
absolute and relative 
effect sizes is 
recommended 
 
Ancillary analyses 
18 
Results of any other 
analyses performed, 
including subgroup 
analyses and adjusted 
analyses, distinguishing 
pre-specified from 
exploratory 
 
The primary and secondary outcomes results are described in the “Results” section of 
the manuscript. 
Harms  
19 
All important harms or 
unintended effects in each 
group 
 

22 
 
Not relevant 
Discussion  
 
 
 
Limitations  
20 
Trial limitations, 
addressing sources of 
potential bias, 
imprecision, and, if 
relevant, multiplicity of 
analyses 
In addition, take into account 
the choice of the comparator, 
lack of or partial blinding, 
and unequal expertise of care 
providers or centers in each 
group 
Generalizability 
21 
Generalizability (external 
validity, applicability) of 
the trial findings 
Generalizability (external 
validity) of the trial findings 
according to the intervention, 
comparators, patients, and 
care providers and centers 
involved in the trial 
Generalisability to clusters 
and/or individual participants 
(as relevant) 
Interpretation 
22 
Interpretation consistent 
with results, balancing 
benefits and harms, and 
considering other relevant 
evidence 
 
The above are described in the “Discussion” section of the manuscript. 
Other 
information 
 
 
 
Registration 
23 
Registration number and 
name of trial registry 
 
The registration number is reported in the abstract of the manuscript. 

23 
 
Protocol  
24 
Where the full trial 
protocol can be accessed, 
if available 
 
Trial registration number: NCT02998203 
The full trial protocol is included here and in the clinicaltrials.gov website  
Funding  
25 
Sources of funding and 
other support (such as 
supply of drugs), role of 
funders 
 
The trial was designed by the Cyprus International Institute for Environmental and 
Public Health and neither the funder (EU LIFE+ programme) nor the sponsoring 
organic products companies were involved with the design or conduct of the trial and 
they were not involved in data collection or analysis.  
 
 
Supplementary References 
1. Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P, for the CONSORT NPT 
Group. CONSORT Statement for Randomized Trials of Nonpharmacologic 
Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic 
Trial Abstracts. Ann Intern Med 2017;167(1):40.  
2. Campbell MK, Piaggio G, Elbourne DR, Altman DG, for the CONSORT Group. 
Consort 2010 statement: extension to cluster randomised trials. BMJ 
2012;345(sep04 1):e5661–e5661.  
3. European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition and 
Allergies (NDA), Scientific Opinion on Dietary Reference Values for energy. 
EFSA Journal 2013; 11(1): 3005. doi:10.2903/j.efsa.2013.3005. 
4. ATSDR - Toxicological Profile: Pyrethrins and Pyrethroids [Internet]. [cited 2018 
May 23];Available from: 
https://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=787&tid=153 

24 
 
5. Harada, KH, Tanaka K, Sakamoto H et al. Biological Monitoring of Human 
Exposure to Neonicotinoids Using Urine Samples, and Neonicotinoid Excretion 
Kinetics. PLoS ONE 2016; 11(1). doi: 10.1371/journal.pone.0146335. 
6. NHANES. Anthropometry Procedures Manual. 2007. [cited 2018 May 17]; 
Available from:  https://wwwn.cdc.gov/nchs/data/nhanes/2007-
2008/manuals/manual_an.pdf\ 
7. De Onis M. Development of a WHO growth reference for school-aged children and 
adolescents. Bull World Health Organ 2007; 85(09): 660–7. 
8. Dupont WD and Plummer WD. PS: Power and Sample Size Calculation version 
3.1.2, 2014. http://biostat.mc.vanderbilt.edu/wiki/Main/PowerSampleSize 
9. Koenig W. Update on C-reactive protein as a risk marker in cardiovascular disease. 
Kidney Int 2003;63:S58–61.  
10. Dourado GKZS, Cesar TB. Investigation of cytokines, oxidative stress, metabolic, 
and inflammatory biomarkers after orange juice consumption by normal and 
overweight subjects. Food Nutr Res 2015;59(1):28147.  
11. Huang T, Larsen KT, Møller NC, Ried-Larsen M, Frandsen U, Andersen LB. 
Effects of a multi-component camp-based intervention on inflammatory 
markers and adipokines in children: A randomized controlled trial. Prev Med 
2015;81:367–72.  
12. Izadpanah A, Barnard RJ, Almeda AJE, et al. A short-term diet and exercise 
intervention ameliorates inflammation and markers of metabolic health in 
overweight/obese children. Am J Physiol-Endocrinol Metab 2012;303(4):E542–
50.  
13. Helsel DR. More than obvious: better methods for interpreting nondetect data. 
Environ Sci Technol 2005;39:419A-423A.