A Randomized, Double-blind, Placebo-controlled, Parallel Study, to Assess the Effect of Bifidobacterial Supplementation on Bowel Movements.
Phase: NA
Conditions: Infrequent Bowel Movements
Sponsor: Morinaga Milk Industry Co., LTD

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A RANDOMIZED, DOUBLE-BLINDED, 
PLACEBO-CONTROLLED, PARALLEL 
STUDY, TO ASSESS THE EFFECT OF 
BIFIDOBACTERIAL SUPPLEMENTATION 
ON BOWEL MOVEMENTS 
PROTOCOL NUMBER AFCRO-171 
 
Version Number: 1.0   
Date: 03 October 2023 
  
2023 
ATLANTIA CLINICAL TRIALS LTD. 
Heron House Offices, First Floor, 
Blackpool, Cork, Ireland T23 R50R 

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Principal Investigator’s Signature 
 
I have carefully read this protocol entitled ‘A randomized, double-blinded, placebo-controlled, 
parallel study, to assess the effect of Bifidobacterial Supplementation on bowel movements’ and 
agree that the conduct of this study is to be informed by the principles of Good Clinical Practice 
(GCP), the ethical principles that have their origin in the Declaration of Helsinki and further 
described in International Conference on Harmonization (ICH-GCP) E6 (R2), Title 21 of the Code of 
Federal Regulations 50, 56, and 312, General Data Protection Regulation (EU) 2016/679, and 
Clinical Trials Regulation EU No 536/2014 and 2005/28/EC for Good Clinical Practice. 
 
In that it contains all the necessary information required to conduct the study. I agree to conduct 
this study as outlined in the protocol. 
 
I understand that this study will not be initiated without approval of the appropriate Institutional 
Review Board/Independent Ethics Committee, and that all administrative requirements of the 
governing body of the institution will be complied with fully. 
 
Informed written consent will be obtained from all Participants in accordance with the institutional 
requirements as set forth in the terms of the declaration of Helsinki as specified in the good clinical 
practice consolidation guidance issued by the International Conference on Harmonization. 
 
I understand that my signature on the completed case report form(s) indicates that I have carefully 
reviewed each page and accept full responsibility for the contents thereof. 
 
I understand that the information presented in this study protocol is confidential, and I hereby 
assure that no information based on the conduct of the study will be released without prior 
consent from Morinaga Milk Industry, unless the requirement is superseded by the appropriate 
regulatory authority. 
 
 
 

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Synopsis 
 
TITLE 
A randomized, double-blinded, placebo-controlled, parallel study, to assess 
the effect of Bifidobacterial Supplementation on bowel movements. 
STUDY ACRONYM 
N/A 
PROTOCOL NUMBER  
AFCRO-171 
Eudract and/or IND No. 
N/A 
VERSION 
1.0 
Date0/ 
03 October 2023 
SPONSOR 
Morinaga Milk Industry 
PLANNED START OF STUDY 
 
Estimated study 
duration 
 
PRINCIPAL INVESTIGATOR 
Stacey Boetto, FNP-C, NRCME, CCM 
STUDY SITE 
Atlantia Clinical Trials, 142 E. Ontario, Suite 1200, Chicago, Illinois, 60611, 
USA 
RESEARCH AREA/APPLICATION 
FIELD 
Constipation 
PRIMARY OBJECTIVE 
To evaluate the effect of eight weeks daily consumption of B. longum 
compared to Placebo on Spontaneous Bowel Movement (SBM) frequency, in 
a population who experience constipation. 
SECONDARY OBJECTIVES 
To evaluate the effect of eight weeks daily consumption of B. longum 
compared to Placebo, in a population who experience constipation on:  
- SBM frequency measured by the daily bowel diary from baseline to 
week 6. 
- Stool consistency as assessed by the Bristol Stool Scale (BSS). 
- Constipation related symptoms as assessed by Patient Assessment of 
Constipation Symptoms (PAC-SYM) Total Score. 
- Impact of constipation on Quality of life as assessed by Patient 
Assessment of Constipation Quality of Life Questionnaire (PAC-QoL) 
Total Score. 
SAFETY AND TOLERABILITY 
OBJECTIVES 
To evaluate in otherwise healthy adults with constipation, the safety and 
tolerability of consuming two capsules of B. longum consumed daily 
compared to Placebo as assessed by: 
-  Occurrence of any Adverse Events (AEs/SAEs) 
-  Vital signs (Blood Pressure, Heart Rate, and Temperature) 
-   Safety blood parameters  
STUDY DESIGN 
Randomized, double-blinded, placebo-controlled, parallel study in healthy 
adults. 
STUDY POPULATION 
Otherwise, generally healthy adults aged 18 to 65 who regularly experience 
constipation. 
SAMPLE SIZE 
Screen n = 160  
Randomize n = 80 (Two arms with 40 subjects per group) 
Evaluable n = 72 
Expected dropout rate is 10% - dropouts will not be replaced. 

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NUMBER OF SITES 
Single centre; Atlantia Clinical Trials, 142 E. Ontario, Suite 1200, Chicago, 
Illinois, 60611, USA 
STUDY PRODUCT 
I. 
B. longum  
II. 
Placebo 
NUMBER OF ARMS 
2 
 
 
DOSAGE AND REGIMEN 
Two capsules of the Study Product per day, before breakfast, with a glass of 
water for the duration of the study (56 days). 
PARTICIPANT 
SELECTION 
CRITERIA 
Inclusion criteria: 
To be eligible for inclusion, the Participant must fulfil all the following 
criteria: 
1. Is willing to participate in the study and comply with its procedures. 
2. Be able to give written informed consent. 
3. Adults aged ≥18 years and ≤65 years.  
4. Experience less than 3 bowel movements per week within the past 
three months.  
5. ≥25% of bowel movements with stool firmness, less than Type-3 
based on Bristol Stool Scale (BSS), within the past three months. 
6. Record less than 6 bowel movements in eDiary App during the two-
week run-in period. 
7. Is willing to maintain the current diet and level of physical activity 
throughout the study period.  
 
Exclusion criteria: 
The presence of any of the following criteria will exclude the Participant from 
participating in the study: 
1. Participants who are pregnant or wish to become pregnant during 
the study, or who are currently breastfeeding. 
2. Participants currently of childbearing potential, but not using 
continuous effective method of contraception, as outlined below: 
a. Complete abstinence from intercourse two weeks prior to 
administration of the Study Product, throughout the 
clinical study, until the completion of follow-up procedures 
or for two weeks following discontinuation of the Study 
Product in cases where Participant discontinues the study 
prematurely. (Participants utilizing this method must agree 
to use an alternate method of contraception if they should 
become sexually active and will be queried on whether 
they have been abstinent in the preceding two weeks 
when they present to the clinic for the final Visit). 
b. Has a male sexual partner who is surgically sterilized prior 
to the Screening Visit and is the only male sexual partner 
for that Participant. 
c. 
Sexual partner(s) is/are exclusively female. 
d. Use of acceptable method of contraception, such as a 
spermicide, mechanical barrier (e.g., male condom, female 
diaphragm), tubal ligation, or contraceptive pill.  The 

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Participant must be using this method for at least one 
week prior to and one week following the end of the study. 
e. Use of any intrauterine device (IUD) or contraceptive 
implant. The Participant must have the device inserted at 
least two weeks prior to the first Screening Visit, 
throughout the study, and two weeks following the end of 
the study. 
3. Participants reporting current, or historical alcohol or drug abuse in 
past year.  
4. Participants who have quit smoking in the 6-months prior to 
screening. 
5. Participants with a known allergy to the Study Product’s active or 
inactive ingredients.  
6. Participants with a chronic disease who require long-term 
medication throughout the whole study period. 
7. Participants with a significant acute, chronic or un-controlled 
coexisting illness or is taking medication/supplements that would 
put the Participant at risk or confound the interpretation of the 
study results, as judged by the investigator.   
8. Participants who regularly take medications, that are thought to 
affect defecation, including regular laxative use. (Occasional 
laxative use (PRN) < 3 times per month is acceptable). 
9. Participants who regularly consume supplements that are thought 
affect defecation, including but not limited to fiber, iron, and 
magnesium.   
10. Participants who are consuming oral antibiotics at screening, during 
run-in and for the duration of the study. 
11. Participants who have consumed probiotic supplements and 
prebiotic supplements eight weeks prior to Visit 2.  
12. Participants who have consumed fermented foods, that aid in 
bowel movement improvement such as yogurt, kefir, sauerkraut, 
kimchi, soy-based fermented food, miso, natto and fermented 
cheese, etc. within the four weeks prior to the Visit 2. 
13. Participants who are diagnosed with or undergoing treatment for 
any gastrointestinal conditions such as coeliac disease, diarrhea, 
Crohn’s disease, ulcerative colitis, irritable bowel syndrome, 
diverticulosis, stomach or duodenal ulcers, gastroesophageal reflux 
disease (GERD) or have undergone significant gastrointestinal 
surgery (appendectomy allowed).   
14. Participants diagnosed with clinical depression, Parkinson’s disease, 
anxiety or an anxiety related disorder, who are undergoing 
treatment with medication. 
15. Participants with clinically significant abnormal laboratory results at 
screening. 
16. Individuals who are cognitively impaired and/or who are unable to 
give informed consent.  
17. Participants may not be participating in other clinical studies. If the 
participant has previously taken part in an experimental study, the 

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Investigator must ensure sufficient time has elapsed before entry to 
this study to ensure the integrity of the results. 
18. Any Participant who is an employee of the investigational site or an 
Atlantia Clinical Trials employee or their close family member or a 
member of their household.  
19. Individuals who, in the opinion of the investigator, are considered 
to be poor attendees or unlikely for any reason to be able to comply 
with the study. 
 
STATISTICAL CONSIDERATIONS 
All statistical elements of the study will be informed by the principles of the 
International Conference on Harmonization -Good Clinical Practice (ICH-
GCP) documents and executed by the study statistician under the standard 
operating procedures for Atlantia Clinical Trials Ltd. Details about these 
elements will be available in a Statistical Analysis Plan (SAP) which will be 
written prior to first Participant randomized and finalized prior to database 
lock. Any deviations from the SAP and/or additional analysis after database 
lock should be fully described and justified in the clinical study report. The 
SAP will be developed by the study statistician, in close collaboration with 
the study PI and study Sponsor. All analyses will be conducted using IBM SPSS 
Statistics Software with figures generated using GGPLOT script in e R Project 
for Statistical Computing, as appropriate. Reporting of the statistical results 
will be informed by the principles of ICH-GCP and CONSORT. 
ETHICAL, 
LEGAL, 
AND 
REGULATORY REQUIREMENTS 
An application will be submitted to the Institutional Review Board (IRB) for 
approval of the study, prior to the study starting. 
This study will be conducted according to the principles of ICH-GCP and the 
Declaration of Helsinki. 
The study will be registered by Morinaga Milk Industry at clinicaltrials.gov.  
 
 

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Study Overview  
 
 
 
 

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Abbreviations  
 
AE 
Adverse Event 
AR 
Adverse Reaction 
BDR 
Blinded Data Review 
BMI 
Body Mass Index 
BSS 
Bristol Stool Scale 
CFU 
Colony Forming Units 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture  
EP 
Enrolled Population 
GERD 
Gastroesophageal Reflux Disease 
GI 
Gastrointestinal 
GRAS 
Generally Recognized As Safe 
ICH-GCP 
International Council for Harmonization- Good Clinical Practice 
IDMC 
Independent Data Monitoring Committee 
IEC/IRB 
Independent Ethics Committee/Institutional Review Board 
ISF 
Investigator Site File 
ITT 
Intention-to-Treat  
IWRS 
Interactive Web Response System 
LPLV 
Last Participant Last Visit  
MedDRA 
Medical Dictionary for Regulatory Activities 
PAC-QoL 
Patient Assessment of Constipation Quality of Life 
PAC-SYM 
Patient Assessment of Constipation Symptoms 
PI 
Principal Investigator 
PP 
Per Protocol population  
PT 
Preferred Term 
S 
Safety Population 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan  
SAR 
Suspected Adverse Reaction 
SBM 
Spontaneous Bowel Movement, defined as no manual maneuver and no laxatives,  
enemas, or suppositories in the preceding 24 hours 
SOC 
System Organ Classification 
SOP 
Standard Operating Procedure  
SP 
Study Product  
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TFL 
Tables, Figures, Listings 
TMF 
Trial Master File 
 
 

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Table of Contents 
SYNOPSIS 3 
STUDY OVERVIEW 
7 
ABBREVIATIONS 
8 
1 
INTRODUCTION 
11 
1.1 
Background information 
11 
1.2 
Study Product 
11 
1.3 
Rationale for conducting the clinical study 
11 
2 
OBJECTIVES 
11 
2.1 
Primary objective 
11 
2.1.1 
Primary endpoint 
12 
2.2 
Secondary objectives 
12 
2.2.1 
Secondary endpoints 
12 
2.3 
Exploratory objective(s) 
13 
2.3.1 
Exploratory endpoints 
13 
2.4 
Safety objectives and tolerability objective(s) and endpoint variables 
13 
3 
STUDY DESIGN 
14 
3.1 
Duration of clinical study 
14 
3.2 
Duration of clinical study per Participant 
14 
4 
PARTICIPANTS AND SITE 
14 
4.1 
Number of Participants 
14 
4.2 
Clinical study population 
14 
4.3 
Inclusion criteria 
14 
4.4 
Exclusion criteria 
14 
4.5 
Randomization, blinding, and treatment allocation 
16 
4.6 
Emergency Unblinding procedure 
16 
4.7 
Number of sites 
17 
5 
STUDY PRODUCT AND SUPPLEMENTATION REGIMEN 
17 
5.1 
Study Product 
17 
5.1.1 
Study Product name and formulation 
17 
5.2 
Other product name and formulation 
17 
5.2.1 
Placebo Product: 
17 
5.3 
Packaging and labelling 
17 
5.4 
Handling and storage conditions 
17 
5.5 
Supplementation regimen 
18 
5.5.1 
Dosage regimen and dose adjustment 
18 
5.6 
Compliance 
18 
5.7 
Warnings and precautions 
18 
5.8 
Concomitant treatments/supplements and restrictions 
18 
5.9 
Rescue Medication 
19 
6 
STUDY PROCEDURES 
19 
6.1 
Recruitment procedures 
21 
6.2 
Obtaining informed consent 
21 
7 
E-DIARY/QUESTIONNAIRE DATA COLLECTION 
21 

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7.1 
Daily eDiary Questions 
21 
7.2 
eDiary Questionnaires 
21 
7.2.1 
Patient Assessment of Constipation Symptoms (PAC-SYM) Questionnaire 
21 
7.2.2 
Patient Assessment of Constipation – Quality of Life (PAC-QoL) Questionnaire 
21 
7.3 
3-Day Food diary 
21 
8 
BIOLOGICAL MEASUREMENTS AND ASSESSMENTS 
22 
8.1 
Blood sample collection 
22 
8.1.1 
Failed or partial blood draws 
22 
8.1.2 
Rejected blood samples or failed blood sample analysis 
22 
8.2 
Storage of Samples 
22 
8.3 
Shipment of Samples 
22 
8.4 
Analysis of Samples 
22 
9 
EARLY PARTICIPANT WITHDRAWAL 
22 
10 
DATA PROCESSING 
23 
10.1 
Case Report Form 
23 
10.1.1 
Electronic Data Capture 
23 
10.1.2 
Data Management 
24 
11 
SAFETY AND TOLERABILITY 
25 
11.1 
Definitions and Standards 
25 
11.2 
Adverse event assessment 
25 
11.2.1 
Causality Assessment 
26 
11.2.2 
Severity/Intensity 
26 
11.2.3 
Outcome of event 
27 
11.2.4 
Clinical laboratory and other safety evaluations 
27 
11.3 
Pregnancy 
27 
11.4 
Safety Management 
28 
11.4.1 
Procedures 
28 
11.5 
Responsibilities 
28 
12 
ETHICAL CONSIDERATIONS 
29 
12.1 
Local Regulations and Declaration of Helsinki 
29 
12.2 
GCP Management Directive 
29 
12.3 
Informed Consent 
30 
12.4 
IRB/IEC approval 
30 
12.5 
Changes to Protocol 
30 
12.6 
Protocol Adherence 
31 
13 
CONFIDENTIALITY 
31 
13.1 
Data 
31 
13.2 
Participant Pseudonymity 
31 
13.3 
Participants’ compensation / remuneration 
31 
14 
STUDY DOCUMENTATION AND RECORD KEEPING 
31 
14.1 
Protocol amendments 
31 
14.2 
Investigator Site File 
31 
14.2.1 
Source document and source data verification 
32 
15 
MONITORING 
32 
15.1 
Quality assurance and quality control 
33 
16 
FINAL STUDY REPORT 
33 
17 
ARCHIVING 
33 
18 
REFERENCES 
33 
 

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1 
Introduction 
1.1 
Background information 
Probiotics have been reported to have a beneficial effect on the intestines, and Bifidobacteria, in 
particular, have shown functionality in relieving constipation(1). For this study, bowel movements are 
defined as any bowel movement, irrespective of its characteristics. In contrast, Spontaneous Bowel 
Movements (SBM) are defined as no manual maneuver and no laxatives, enemas, or suppositories in 
the preceding 24 hours. To obtain a holistic understanding of the effect of B. longum on 
gastrointestinal function, it is essential to select an appropriate type of bowel movement as an 
evaluating indicator. SBMs represent a natural and unstimulated event that reflects the body's ability 
to regulate bowel movements without external factors. Including SBMs in the study allows for a more 
comprehensive evaluation of bowel function. 
 
1.2 
Study Product 
B. longum, which is isolated from infants, has been proven to be safe and has been widely used in 
fermented foods and supplements for a long time.  
 
In this study, the active Study Product, B. longum capsule, contains lyophilized powder of live B. 
longum at 5 × 109 CFU/capsule blended with corn starch, and placebo capsule contains corn starch 
only. 
 
High survivability of B. longum in host feces has been identified after oral intake. As a bifidobacteria, 
B. longum produces not only lactic acid but also a significant amount of acetic acid in the colon, which 
can reduce the luminal pH and improve the bowel movement. It is considered that B. LONGUM can 
promote defecation and improve constipation. 
 
1.3 
Rationale for conducting the clinical study 
Due to limitations in recruiting clinical subjects, previous clinical trials investigating the effects of B. 
longum on constipation improvement only focused on East Asian individuals as participants. 
Consequently, there is currently a lack of clinical evidence regarding the efficacy of B. longum in 
regulation of bowel movement frequency and determining the appropriate dosage for European and 
North American populations, which have significantly different ethnicities, diets, and lifestyle habits.  
 
 
2 
Objectives 
2.1 Primary objective 
To evaluate the effect of eight weeks daily consumption of B. longum compared to Placebo on 
Spontaneous Bowel Movement (SBM) frequency, in a population who experience constipation. 

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2.1.1 
Primary endpoint  
Change in mean weekly frequency of SBM, as measured by the daily bowel diary from 
baseline to the end of intervention. Frequency will be defined as the mean weekly number 
of SBM during the 2-week run-in period prior to Visit 2, for baseline, and during the final         
2-week period of the intervention prior to Visit 3, for end of intervention.   
 
2.2 Secondary objectives 
To evaluate the effect of eight weeks daily consumption of B. longum compared to Placebo, in a 
population who experience constipation on:  
- 
SBM frequency measured by the daily bowel diary from baseline to week 6. 
- 
Stool consistency as assessed by the Bristol Stool Scale (BSS). 
- 
Constipation related symptoms as assessed by Patient Assessment of Constipation 
Symptoms (PAC-SYM) Total Score. 
- 
Impact of constipation on Quality of life as assessed by Patient Assessment of Constipation 
Quality of Life Questionnaire (PAC-QoL) Total Score. 
 
2.2.1 
Secondary endpoints 
• 
Change in mean weekly frequency of SBM, as measured by the daily bowel diary from 
baseline to Week 6. Frequency will be defined as the mean weekly number of SBM from 
baseline to Week 1-2, baseline to Week 3 -4, baseline to Week 5-6. 
• 
Change in mean daily stool consistency as measured from the Bristol Stool Scale (BSS) in the 
daily bowel dairy from baseline to the end of intervention. Stool Consistency will be defined 
as the mean daily stool consistency during the 2-week run-in period prior to Visit 2, for 
baseline, and during the final 2-week period of the intervention, for end of intervention.   
• 
Change in self-reported constipation related  symptoms as assessed by the Total Score of the 
Patient Assessment of Constipation Symptoms (PAC-SYM) Questionnaire  from baseline to:  
- Week 4  
- Week 8  
• 
Change in self-reported impact of constipation on Quality of Life as assessed by the Total 
Score of the Patient Assessment of Constipation Quality of Life (PAC-QoL) Questionnaire 
from baseline to:  
- Week 4 
- Week 8 

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2.3 Exploratory objective(s) 
To evaluate the effect of eight weeks daily consumption of B. longum compared to Placebo, in a 
population who experience constipation on:  
• 
PAC-SYM sub-scores (Abdominal, Rectal, and Stool related symptoms) 
• 
PAC-QoL sub-scores (Physical Discomfort, Psychosocial Discomfort, Treatment Satisfaction, 
and Worries/ Concerns) 
• 
Microbiome and fecal metabolite analysis (stool sampling only, analysis by Morinaga Milk 
Industry) 
 
2.3.1 
Exploratory endpoints 
• 
Change in PAC-SYM sub-scores (Abdominal, Rectal, and Stool related symptoms) from 
baseline to:  
- Week 4  
- Week 8 
• 
Change in PAC-QoL sub-scores (Physical Discomfort, Psychosocial Discomfort, Treatment 
Satisfaction, and Worries/ Concerns) from baseline to:  
- Week 4 
- Week 8 
 
2.4 Safety objectives and tolerability objective(s) and endpoint variables 
2.4.1 
Safety and tolerability objective(s) 
To evaluate in otherwise healthy adults with constipation, the safety and tolerability of B. 
longum consumed twice daily compared to Placebo as assessed by: 
- Occurrence of any Adverse Events (AEs/SAEs) 
- Vital signs (Blood Pressure, Heart Rate, and Temperature) 
-  Safety blood parameters  
 
2.4.2 
Safety and tolerability endpoint variable(s) 
• Incidence of AEs per group by product causality. 
• Incidence of mild, moderate, and severe AEs per treatment group by product causality. 
• Incidence of AEs by MedDRA System Organ Classification (SOC) and preferred term (PT) by 
product allocation. 
• Incidence of Safety Blood Parameter AEs by product allocation. 

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• Incidence of Vital Parameter (blood pressure, heart rate, and body temperature) AEs by 
product allocation. 
• Incidence of SAEs per group by product causality. 
3 
Study Design 
Randomized, double-blinded, placebo-controlled, parallel study in healthy adults. 
 
3.1 
Duration of clinical study 
The study will involve three on-site visits over a period of up to eleven weeks.  
 
3.2 
Duration of clinical study per Participant 
• 
Screening: 1 - 7 days 
• 
Run-in phase: 14 days 
• 
Intervention phase:  56 days 
• 
Total time: 77 days  
4 
Participants and site 
4.1 
Number of Participants 
Screen n = 160  
Randomize n = 80 (Two arms with 40 subjects per group) 
Evaluable n = 72 
Expected dropout rate is 10% - dropouts will not be replaced. 
 
4.2 
Clinical study population 
Otherwise, generally healthy adults aged 18 to 65 who regularly experience constipation. 
 
4.3 
Inclusion criteria 
To be eligible for inclusion, the Participant must fulfil all the following criteria: 
1. Is willing to participate in the study and comply with its procedures. 
2. Be able to give written informed consent. 
3. Adults aged ≥18 years and ≤65 years.  
4. Experience less than 3 bowel movements per week within the past three months.  
5. ≥25% of bowel movements with stool firmness, less than Type-3 based on Bristol Stool Scale 
(BSS), within the past three months. 
6. Record less than 6 bowel movements in eDiary App during the two-week run-in period. 
7. Is willing to maintain the current diet and level of physical activity throughout the study period.  
 
4.4 
Exclusion criteria 
Participants will be excluded from the study if they meet any of the following criteria: 
1. Participants who are pregnant or wish to become pregnant during the study, or who are 
currently breastfeeding. 

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2. Participants currently of childbearing potential, but not using continuous effective method of 
contraception, as outlined below: 
a. Complete abstinence from intercourse two weeks prior to administration of the Study 
Product, throughout the clinical study, until the completion of follow-up procedures or 
for two weeks following discontinuation of the Study Product in cases where 
Participant discontinues the study prematurely. (Participants utilizing this method 
must agree to use an alternate method of contraception if they should become sexually 
active and will be queried on whether they have been abstinent in the preceding two 
weeks when they present to the clinic for the final Visit). 
b. Has a male sexual partner who is surgically sterilized prior to the Screening Visit and is 
the only male sexual partner for that Participant. 
c. Sexual partner(s) is/are exclusively female. 
d. Use of acceptable method of contraception, such as a spermicide, mechanical barrier 
(e.g., male condom, female diaphragm), tubal ligation, or contraceptive pill.  The 
Participant must be using this method for at least one week prior to and one week 
following the end of the study. 
e. Use of any intrauterine device (IUD) or contraceptive implant. The Participant must 
have the device inserted at least two weeks prior to the first Screening Visit, 
throughout the study, and two weeks following the end of the study. 
3. Participants reporting current, or historical alcohol or drug abuse in past year.  
4. Participants who have quit smoking in the 6-months prior to screening. 
5. Participants with a known allergy to the Study Product’s active or inactive ingredients.  
6. Participants with a chronic disease who require long-term medication throughout the whole 
study period. 
7. Participants with a significant acute, chronic or un-controlled coexisting illness or is taking 
medication/supplements that would put the Participant at risk or confound the interpretation 
of the study results, as judged by the investigator.   
8. Participants who regularly take medications, that are thought to affect defecation, including 
regular laxative use. (Occasional laxative use (PRN) < 3 times per month is acceptable). 
9. Participants who regularly consume supplements that are thought affect defecation, including 
but not limited to fiber, iron, and magnesium.   
10. Participants who are consuming oral antibiotics at screening, during run-in and for the 
duration of the study. 
11. Participants who have consumed probiotic supplements and prebiotic supplements eight 
weeks prior to Visit 2.  
12. Participants who have consumed fermented foods, that aid in bowel movement improvement 
such as yogurt, kefir, sauerkraut, kimchi, soy-based fermented food, miso, natto and 
fermented cheese, etc. within the four weeks prior to the Visit 2. 
13. Participants who are diagnosed with or undergoing treatment for any gastrointestinal 
conditions such as coeliac disease, diarrhea, Crohn’s disease, ulcerative colitis, irritable bowel 
syndrome, diverticulosis, stomach or duodenal ulcers, gastroesophageal reflux disease (GERD) 
or have undergone significant gastrointestinal surgery (appendectomy allowed).   

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14. Participants diagnosed with clinical depression, Parkinson’s disease, anxiety or an anxiety 
related disorder, who are undergoing treatment with medication. 
15. Participants with clinically significant abnormal laboratory results at screening. 
16. Individuals who are cognitively impaired and/or who are unable to give informed consent.  
17. Participants may not be participating in other clinical studies. If the participant has previously 
taken part in an experimental study, the Investigator must ensure sufficient time has elapsed 
before entry to this study to ensure the integrity of the results. 
18. Any Participant who is an employee of the investigational site or an Atlantia Clinical Trials 
employee or their close family member or a member of their household.  
19. Individuals who, in the opinion of the investigator, are considered to be poor attendees or 
unlikely for any reason to be able to comply with the study. 
 
4.5 
Randomization, blinding, and treatment allocation 
Participants who meet the eligibility criteria/have successfully completed the Screening Visit will be 
randomized on a 1:1 basis to the two arms of this study to determine whether they receive the Study 
Product (SP) or the Placebo. The randomization list and procedure will be prepared by a statistician 
not involved in the conduct phase of the study (i.e., blinded data reviews) and securely conveyed to 
the science and quality team.  
 
Randomization will be completed using a minimization procedure via an Interactive Web Response 
System (IWRS) with the aim to minimize imbalance on sex and bowel movement frequency. Each 
eligible participant will be assigned a randomization number, which corresponds to one of the two 
products. The relationship between the randomization number and the product assignment will be 
unknown to the clinical research team, the sponsor, study site staff, or the Participants, i.e., the study 
will be double blinded. 
 
Blinding of both study team and Participants will be ensured by only providing access to the 
randomization list to the science and quality team which is stored in the quality drive.  
 
4.6 
Emergency Unblinding procedure  
The investigator will receive access to an IWRS to unblind if required. 
 
Unblinding access is for emergency use only, i.e., when it becomes absolutely necessary to know what 
treatment the participant receives in case of a serious adverse event (SAE) in order to manage the 
participant’s condition. A broken code requires the participant to be withdrawn from the clinical trial. 
 
The investigator should promptly document and notify the Sponsor any premature unblinding (e.g., 
accidental unblinding, unblinding due to a SAE) of the IP. The date, time, and reason for unblinding 
must be written onto the envelope and signed by the investigator. 
 
If appropriate, the monitor will check the IWRS during monitoring visits and obtain adequate 
documentation for any unblinding.   
 

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4.7 
Number of sites 
This is a single-site study, with all Participants to be recruited by Atlantia Clinical Trials. 
5 
Study Product and Supplementation Regimen 
5.1 
Study Product 
5.1.1 Study Product name and formulation 
• 
Product name: Bifidobacterial capsule, Morinaga Milk Industry, 5-33-1 Shiba, Minato-ku, 
Tokyo, 108-8403, Japan. 
• 
Active compound: Bifidobacterium longum, 1 × 1010 CFU 
• 
Capsules: 5 × 109 CFU active compound per capsule 
 
5.2 
Other product name and formulation 
5.2.1 Placebo Product: 
• 
Ingredients: 0 CFU compound per capsule 
 
5.3 
Packaging and labelling 
The label will contain the following information:  
Atlantia Study Code - AFCRO-171 
Sponsor: Morinaga Milk Industry  
Participant Randomization Code 
Investigator name  
For clinical study use only 
Batch/Lot number 
Storage conditions / keep away from children (if applicable) 
Directions for use  
Emergency Contact Number 
Expiry date 
 
Packaging will be performed by Morinaga Milk Industry and labelling will be carried out by Atlantia 
Clinical Trials, 142 E. Ontario, Suite 1200, Chicago, Illinois, 60611, USA.  
 
Each aluminum bag will contain 28 capsules of either the SP or the Placebo. Each Participant will be 
provided with five aluminum bags (total 140 capsules) allowing for two capsules per day, for 56 days 
and an extra 14-day supply, in case of delay of visit or loss of Study Product. 
 
5.4 
Handling and storage conditions 
Study Product will be stored in a secure area with restricted access. The Principal Investigator/Sub-
Investigator agrees that the Study Product will be dispensed only to study Participants who have 
provided written consent. Compliance will be monitored by return of all product containers (used and 
unused). Any deviations will be noted in the source documents and the Participant’s eCRF. The Study 
Product should be stored at refrigerated temperature, 2°- 8°C (36°-46°F) before being dispensed to 
the Participants.  
 
Study Participants will be instructed to store the Study Product at room temperature.  

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5.5 
Supplementation regimen 
5.5.1 
Dosage regimen and dose adjustment 
 
• Participants will be provided an eight-week supply of Study Product (5 bags) at Visit 2 in a 
transparent UniPak, wherein 4 bags will be used for consumption during the eight-week 
intervention period and 1 bag will be provided as an additional supply in case of delay in study visit 
or loss of Study Product. 
• Participants will be instructed to consume two capsules of the Study Product per day, before 
breakfast, with a glass of water for the duration of the study (56 days).  
• If the dose is missed, the Participant should consume the same dosage after dinner on the same day. 
• Missed doses should not be moved to the following day. 
• Participants will be instructed to return any unused Study Product at Visit 3. 
• Participants will consume their first dose of Study Product on the day following their Visit 2 (Day 1) 
and will consume their final dose of Study Product on the morning of their Visit 3 (Day 56). 
 
In the event of significant worsening, severe or intolerable new GI symptoms, or other AEs after 
product consumption/use or overdose, the dose may be interrupted or titrated after consultation with 
the sponsor representative and PI/Sub-Investigator. The dose may be temporarily interrupted for the 
shortest time possible without increasing the risk to the Participants continued safety on the study. If 
the Participant requires dose interruption for more than three days with no improvement in GI 
symptoms and/or other AEs, then consultation with the Sponsor representative and PI/Sub-
Investigator must occur, and the Participant may be discontinued from SP.  
 
5.6 
Compliance 
Individual Product Dispensing and Accountability Logs will be completed for each Participant and kept 
up to date. The log lists the Participant Number, the date of dispensing, number of capsules dispensed, 
the number of capsules returned, and the date returned. Participants will be instructed to return all 
unused product. If applicable, the monitor will inspect the amount of SP dispensed and returned. 
 
Compliance will be assessed at Visit 3, in the statistical analysis, overall compliance will be considered. 
If a Participant states that they have not returned all unused capsules (e.g., forgot to return, loss, 
contaminated), details will be recorded in the eCRF. Participants must have consumed a minimum of 
80% of the Study Product, in order to be deemed product compliant. Non-compliant Participants will 
be included in the Intention-to-Treat (ITT) population set (Analyzed on as-randomized basis) and will 
be excluded withdrawn from the Per-Protocol (PP) analysis. 
 
5.7 
Warnings and precautions 
- 
For clinical study use only. 
- 
Keep out of reach of children. 
 
5.8 
Concomitant treatments/supplements and restrictions 
Participants will be questioned about their general medical history within the previous year, and 
medications within the previous three months. The details of any medication taken will be recorded 
in the Participant case notes and case report form. 

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Participants will be instructed to follow their habitual diet and exercise routine and to not consume 
any disallowed medications, dietary supplements, probiotic, prebiotic supplements, and fermented 
products that could interfere with the assessment of the Study Product for the duration of the study. 
 
5.9 
Rescue Medication  
In case of no bowel movement for more than four days: bisacodyl suppositories or tablets (5- 10 mg) 
or other rescue medication in line with local guidelines at the dose specified in the local guidelines (no 
more than three consecutive days over a period of 1 week) will be allowed as rescue medication. 
Maximum dosage: 15 mg/ day.  
 
Its use needs to be documented at relevant study visits (including concomitant medication, diet, 
supplements, and any related adverse event). The date and time of rescue medication administration 
as well as the name and dosage regimen of the rescue medication must be recorded.  
 
The study site will not supply any rescue medication. 
6 
Study Procedures 
 
Table 2. Schedule of Assessments 
 
Assessment periods 
Visit Number 
Visit 1 
Run-in 
Visit 2 
Visit 3 
 
Early 
Termination 
Visit 
Visit Window 
Day -21 to -15 
Day -14 to -1 
Day 0 
Day 56 
+ 3 Days 
Study Phase 
Screening 
Run-in 
Intervention 
Screening 
Informed consent 
x 
 
 
 
 
Eligibility Screen 
x 
x 
 
 
Demographic/ 
Lifestyle data 
x 
 
 
 
Medical history 
x 
x 
 
x 
Anthropometric 
measurements 
(Height, weight, BMI) 
x 
 
 
 
Prior and concomitant 
medications  
x 
x 
x 
x 
Safety and Tolerability 
Vitals (Blood pressure, 
heart 
rate, 
temperature) 
x 
 
x 
x 
x 
Safety 
blood 
parameters 
x 
 
 
 

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All visits will have the option of being completed remotely via telephone where feasible based on the 
assessments required for the visit.  
 
Assessment periods 
Visit Number 
Visit 1 
Run-in 
Visit 2 
Visit 3 
 
Early 
Termination 
Visit 
Visit Window 
Day -21 to -15 
Day -14 to -1 
Day 0 
Day 56 
+ 3 Days 
Study Phase 
Screening 
Run-in 
Intervention 
(Chemistry profile and 
Hematology profile) 
AE/SAE 
 
<--------------------------> 
x 
Assessments/Procedures 
Stool 
sample 
collection 
 
Dispense 
stool 
collection kit 
x 
 
x 
 
 
Return Stool Sample 
for 
microbiome 
analysis 
 
x 
x 
x 
Urine collection 
 
Urine pregnancy test 
x 
 
x 
x 
x 
Questionnaires  
 
Download eDiary App 
x 
 
 
 
 
Bowel Movement & 
Bristol Stool Scale 
 
x 
<--------------------------> 
 
PAC-SYM (Week 0, 4 
& 8) 
 
 
<--------------------------> 
 
PAQ-QoL (Week 0, 4  
& 8) 
 
 
<--------------------------> 
 
Delete eDiary App 
 
 
 
x 
x 
Dietary analysis 
 
Dispense 3-Day food 
Diary 
x 
 
x 
 
 
Return 
3-Day 
food 
Diary 
 
x 
x 
x 
Supplementation 
 
Randomization  
 
 
x 
 
 
Administer SP 
 
x 
 
 
Return SP 
 
 
x 
x 
Assess SP Compliance 
 
 
x 
x 
Participant 
Compensation 
 
Dispense Participant 
Compensation 
 
 
 
x 
x 

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6.1 
Recruitment procedures 
Participants may be recruited through Atlantia’s database, social media, radio advertisements and 
adverts in local newspapers. Participants will undergo an initial pre-screening questionnaire and will 
be asked questions regarding their age, general health, and medications. Eligible Participants will be 
scheduled for a Screening Visit.  
 
6.2 
Obtaining informed consent 
Participants will receive a copy of the Informed Consent Form, via email prior to the Screening Visit. 
Participants who are foreseen to fulfil the inclusion/exclusion criteria for enrolment into the clinical 
study will be asked to give informed consent in writing prior to any clinical study specific procedures. 
Both the Participant (or legal representative) and PI or a person designated by the PI (if acceptable by 
local regulations) will sign and date the informed consent form.  All Participants who have signed the 
informed consent form will be listed on the Participant Screening and Enrolment Log and Participant 
Identification Log. 
 
7 
E-Diary/Questionnaire Data Collection 
7.1 Daily eDiary Questions 
Participants will download an eDiary App at Visit 1 which they will be directed to complete throughout 
the study. This eDiary will record the following information: 
- 
Bowel movement diary will collect daily data relating to stool frequency and stool consistency. 
- 
AEs and medication use (Weekly) 
- 
Study Product compliance (Weekly) 
 
7.2  eDiary Questionnaires 
7.2.1 Patient Assessment of Constipation Symptoms (PAC-SYM) Questionnaire 
- Participants will complete the questionnaire at Week 0, Week 4, and Week 8. 
- PAC-SYM collects self-reported constipation related symptoms – has a Total Score, and three 
sub-scores for key symptom areas (Abdominal, Rectal, and Stool related symptoms). 
 
7.2.2 Patient Assessment of Constipation – Quality of Life (PAC-QoL) Questionnaire 
- Participants will complete the questionnaire at Week 0, Week 4, and Week 8. 
- PAC-QoL assessment collects self-reported impact of constipation on Quality of Life -has a 
Total Score, and four sub-scores for key areas of wellbeing (Physical Discomfort, Psychosocial 
Discomfort, Treatment Satisfaction, and Worries & Concerns). 
 
7.3 
3-Day Food diary 
Participants will complete a 3-Day Food Diary, logging any food eaten for three days prior to Visit 2 to 
establish their dietary habits at Baseline, and again at Visit 3 to reassess it at end of intervention. This 
data will be used to confirm that Participants maintained their habitual diet throughout the study via 
evaluation of key dietary components at baseline compared to end-of-intervention (i.e., energy, total 
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8 
Biological measurements and assessments 
 
8.1 
Blood sample collection 
A total of approximately 7.5mL/0.25 fl.oz of blood should be collected from all Participants.  
 
8.1.1 
Failed or partial blood draws 
In the case of a failed attempt at a blood draw, or a partial blood draw which did not successfully 
collect the required amount of blood for analysis, the clinical phlebotomist may either make additional 
attempts on the Participants other arm, or, if willing, the Participant may be asked to return within 
the visit window for a second attempt. This will only be carried out if required and will be entirely at 
the Participant’s discretion.   
 
8.1.2 
Rejected blood samples or failed blood sample analysis 
In the case of a rejected blood sample or failed blood sample analysis, refer to the sub-investigator 
and the Safety Monitoring Plan.  
 
8.2 
Storage of Samples 
All blood and fecal samples will be listed on study specific sample logs and stored at the clinical site 
during the study where applicable. 
 
8.3 
Shipment of Samples 
Shipment of samples will be performed in accordance with the Laboratory manual.       
 
8.4 
Analysis of Samples 
All samples will be analyzed using validated assays and methods.  
9 
Early Participant Withdrawal 
Participants have the right to withdraw from the study at any time for any reason, without giving a 
reason and without penalty or loss of benefits they are entitled to. The PI/Sub-Investigator also has 
the right to discontinue Participants from SP consumption and/or withdrawal from the study if this is 
in the best interest of the Participant or if Participant is persistently not compliant with study 
procedures and SP consumption. 
 
Any of the following conditions may lead to premature withdrawal from SP/study: 
- 
Request by Participant to discontinue for any reason during the study.  
- 
erroneously included / randomized Participant. 
- 
adverse event(s) or concurrent illness that, in the opinion of the PI/Sub-Investigator, warrants 
the Participant’s withdrawal from intervention. 
- 
intake of concomitant medication/dietary supplements prohibited by the protocol. 
- 
Participants who do not follow the requirements of the Protocol, especially those concerning 
safety and/or if the Participant after their enrolment is uncooperative or not willing to comply 
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- 
failure to return for follow-up visits despite numerous attempts to reschedule (lost to follow-
up). 
- 
request by regulatory agencies for termination of supplementation of an individual Participant 
or all Participants under this protocol. 
- 
pregnancy, if a protocol exclusion criterion. 
 
The circumstances of any discontinuation will be in consultation with the Sponsor and must be 
documented in detail in the corresponding study termination form in the case report form. Whenever 
a Participant will be withdrawn from the study for whatever reason, adequate efforts will be made to 
perform a final assessment to include standard medical and laboratory tests which would have been 
done on normal completion of the study. The data of the withdrawn Participants will be documented 
in the clinical study report. 
 
Note: Participants who withdraw prematurely from the study will not be replaced. 
10 Data processing  
10.1 Case Report Form 
10.1.1 Electronic Data Capture 
It is the responsibility of the PI (or designee) to ensure the completeness and accuracy of the electronic 
CRFs (eCRF). One eCRF must be compiled for each Participant participating in the study.  
 
Data required for the analysis will be acquired and transferred electronically to a central database by 
means of an Electronic Data Capture system (the “EDC-tool”). The system operates over the Internet 
according to the principle of online data capture. Data entered by investigators or data managers into 
local computers are directly transferred over the Internet to a central database, without any 
permanent local storage. 
 
High security standards for the transfer and storage study data are guaranteed using technologies 
such as encrypted data transfer, firewalls, and periodic backup to protect centrally stored data. 
Writing access to the system will be limited to authorized personnel and the system will automatically 
keep an audit trail of all entries and corrections to the CRF. Training in the use of the EDC-tool will be 
provided by data management, study coordinator, monitor, or delegates. 
 
The EDC-tool will comprise of an eCRF, designed specifically for this study.  
 
The EDC-tool is operated under an electronic signature, consisting of the combination of an 
identification code and a password. In relation to the present study, passwords and electronic 
signatures will be distributed to users of the EDC tool, and used for entering, modifying, or viewing 
study data. 
 

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It is the responsibility of individuals who received an electronic signature to keep their password secret, 
i.e., not to reveal it to third parties, and to access the EDC-tool, to enter or modify study data using 
the EDC-tool only under their personal identification code and password. 
 
10.1.2 Data Management 
The eCRF is based on the electronic data capture system developed by Clindox, which is fully compliant 
with and a Gold Member of the Clinical Data Interchange Standards Consortium. 
 
The eCRF will be hosted on a dedicated validated stand-alone server placed in a double locked server 
room. All access to the server and other server maintenances will be logged. Study setup and hosting 
will be managed by Clindox and Atlantia according to ICH-GCP and Standard Operating Procedures.  
 
Only authorized access to the eCRF will be possible using encrypted username and password. Roles in 
the system are given according to functions (researcher, monitor, project manager, data manager, 
data analyst etc.). All tasks performed in the eCRF are logged in an audit trail.  
 
The eCRF will contain data ranges and validation checks to maintain an ongoing quality check of data 
entered. All data validation will be performed as part of the system using Data Clarification Report 
tools. Ongoing and prior to database lock a blinded database review will be performed, and any 
discrepancies or missing data will be queried and resolved. A log will be kept on site to document 
location of source data.  
 
Medical history data, adverse events, and prior and concomitant medication data entry will be 
standardized.  
 
The PI/Sub-Investigator and authorized staff at the clinical site can add data to the eCRF and must 
keep the eCRF current to reflect Participant status during the study. A screening and randomization 
number and the date of birth identify the Participants on the eCRF. The study personnel must make a 
separate confidential record of personalized details (name and date of birth) on the Participant 
identification and enrolment log which is kept separately from the eCRF. Once the eCRF for a 
Participant is completed, the PI/Sub-Investigator will approve the data using an electronic signature 
and thereby confirm the accuracy of the data recorded.  
 
Laboratory data will be collected electronically from the laboratory and combined with the other 
clinical data. The data entry of the eCRFs and laboratory data may generate additional requests (Data 
query) to which the researcher is obliged to respond by confirming or modifying the data questioned.  
 
The eCRFs for any Participant leaving the study should be completed at the time of the final Visit or 
shortly thereafter. Any ongoing AEs at the final Visit will be characterized as ‘Ongoing at End of Study’ 
and there will be no further follow up.  

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11 Safety and Tolerability 
11.1 Definitions and Standards 
Adverse Event (AE): 
Any untoward medical occurrence in a Participant involved in a clinical study administered a Study 
Product whether or not related to this product.  
 
An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory 
finding for example), subjective and objective symptom, or disease temporally associated with the use 
of a product, accidents, whether or not considered related to the product or study-related procedure 
and reported by the Participant or observed by the PI/Sub-Investigator. 
 
Serious Adverse Event (SAE): 
Any AE that at any dose fulfils at least one of the following criteria: 
 
1. Is fatal (results in death)  
(note: death is an outcome, not an event) 
2. is life-threatening  
(note: the term “life-threatening” refers to an event in which the Participant was at risk of 
death at the time of the event; it does not refer to an event which could hypothetically have 
caused death had it been more severe) 
3. requires 
inpatient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization  
(note: “inpatient hospitalization” refers to an unplanned, overnight hospitalization) 
4. results in persistent or significant disability/incapacity 
(note: the term means substantial disruption of one’s ability to conduct normal life function) 
5. is a congenital anomaly/birth defect 
(note: congenital anomaly/birth defect in offspring of Participant taking the product 
regardless of time to diagnosis) 
6. is medically significant  
(note: Medical and scientific judgement should be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
Participant or may require intervention to prevent one of the other outcomes listed in the 
definitions above) 
 
Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A suspected Unexpected Serious Adverse Reaction is any adverse reaction for which the nature or 
severity is non consistent with the applicable product information.  
 
11.2 Adverse event assessment 
 
Expectedness: 
An unexpected AE is an event of which the nature or severity is not consistent with the Participant’s 
medical history, concomitant medications, or the applicable product information.  
 

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For purposes of this study, bloating and mild diarrhea may be expected according to previous reports. 
All other AEs reported will be unexpected. 
 
11.2.1 Causality Assessment 
The causality assessment of an AE to the investigational and/or study procedure(s) product will be 
rated as follows: 
 
Unrelated: 
The event is clearly related to other factors such as the Participant’s clinical state, 
therapeutic interventions, or a concomitant medication administered to the 
Participant and does not follow a known response pattern to the Study Product. 
Unlikely:  
The event follows a reasonable temporal sequence from the time of Study Product 
administration, although there is another plausible explanation for the occurrence of 
the event. 
Possible: 
The event follows a reasonable temporal sequence from the time of Study Product 
administration and/or follows a known response pattern to the study treatment but 
could have been produced by other factors such as the Participant’s clinical state, 
therapeutic interventions, or concomitant medications administered to the 
Participant. 
Probable:   
The event follows a reasonable temporal sequence from the time of Study Product 
administration and follows a known response pattern to the Study Product, where the 
event is more likely explained by the product than any other cause.  
Definite: 
The event follows a reasonable temporal sequence from the time of Study Product 
administration and follows a known response pattern to the Study Product and cannot 
be reasonably explained by other factors such as the Participants clinical state, 
therapeutic interventions administered to the Participant and either occurs 
immediately following Study Product, or improves on stopping the Study Product, or 
reappears on repeat exposure, or there is a positive reaction at the application site.  
 
11.2.2 Severity/Intensity 
The severity of AEs must be recorded, including the start and stop dates for each change in severity. 
An event that worsens / increases in severity should be captured as a new event. After initiation of IP 
consumption, worsening of events that started prior to initiating intake of IP must be recorded as new 
AEs (for example, if a patient experiences mild intermittent dyspepsia prior to dosing of IP, but the 
dyspepsia becomes severe and more frequent after first dose of IP has been administered, a new AE 
of severe dyspepsia [with the appropriate date of onset] is recorded in the eCRF).  
  
The severity/intensity of AEs where applicable will be graded on a five-point-scale in accordance with 
the Common Terminology Criteria for Adverse Events:  
  
Grade 1:  
Mild AE - Discomfort noted, but no disruption to normal daily activities  
Grade 2:  
Moderate AE - Discomfort sufficient to reduce or affect normal daily activities  
Grade 3:  
Severe AE - Inability to work or perform normal daily activities  
Grade 4:   
Life threatening or disabling AE  
Grade 5:  
Death related to AE  

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11.2.3 Outcome of event 
The outcome of AEs must be followed up and recorded during the course of the study in the eCRF. 
Outcomes are as follows: 
- 
Recovered 
- 
Recovered with sequelae 
- 
Ongoing 
- 
Fatal 
- 
Unknown/Lost to follow-up 
 
11.2.4 Clinical laboratory and other safety evaluations 
A change in the value of a clinical laboratory, vital sign, or other study assessment can represent an 
AE if the change is a clinically significant worsening from baseline. This includes abnormal assessments 
where there is a shift of a parameter from a normal value to an abnormal value, or a significant 
worsening of an already abnormal value. Clinical significance is defined as an abnormal study 
assessment that leads to a diagnosis (in which case the diagnosis is recorded rather than the abnormal 
assessment) or results in Participant intervention such as further monitoring (excluding confirmatory 
repeat testing) or medical treatment. If, at the end of the treatment phase, there are abnormal clinical 
laboratory, vital sign values or other study assessments which were not present pre-treatment, the 
value observed closest to the start of study treatment should be used as baseline. The PI or Sub-
Investigator should decide, based on the above criteria and the clinical condition of a Participant, 
whether a worsening of an abnormal study assessment is clinically significant and therefore represents 
an AE. 
 
11.3 Pregnancy 
All pregnancies are to be reported from the time of enrolment to the end of follow-up in the 
Participants eCRF and reported using a Pregnancy Report Form. Any report of pregnancy for any study 
Participant must be reported to the Sponsor. Pregnancy itself is not an AE, however it should be 
reported for tracking purposes.  
 
Pregnant Participants must be withdrawn from using the Study Product, and in consultation with the 
Sponsor and/or PI/Sub-Investigator may be withdrawn from the study or asked to remain and 
continue safety monitoring for the remainder of the study. Every effort should be made to gather 
information regarding the pregnancy outcome.  
 
The Participant will be asked to notify the PI/Sub-Investigator of the outcome of the pregnancy (i.e., 
birth, loss, or termination). To help ensure this, the PI/Sub-Investigator will follow-up with the 
Participant until the end of pregnancy or last study Visit whichever occurs first, with the Participant’s 
consent. This request and the Participant’s response will be documented in the Participant’s source 
document. Pregnancy outcome will be determined as live birth, still birth or pregnancy termination.  
 
If the pregnancy is due to a Participant’s failure to comply with the contraceptive requirements of the 
protocol, this should also be documented as a protocol deviation. 
 

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Pregnancy complications such as spontaneous abortion/miscarriage or congenital abnormality are 
considered SAEs and must be reported as such. Note: an elective abortion is not considered an SAE. 
In addition to the above, if the PI/Sub-Investigator determines that the pregnancy meets SAE criteria, 
it must be reported as an SAE. The test date of the first positive urine human chorionic gonadotropin 
test or ultrasound result will determine the pregnancy onset date. 
 
11.4 Safety Management 
11.4.1 Procedures 
All Adverse Events (AEs) occurring during clinical studies are recorded in the electronic Case Report 
Form (eCRF). 
 
Serious adverse events (SAEs) are reported and processed according to the applicable laws and 
regulatory requirements governing the conduct of clinical studies. SAEs must be recorded on the SAE 
Form.  
 
11.5 Responsibilities 
PI or Sub-Investigator will ensure that SAE reporting procedures outlined in the study protocol are 
adhered to and that all required documentation is up-to-date, and that regulatory and IRB/IEC SAE 
reporting procedures are followed. 
 
All clinical research personnel at the study site (PI, Sub-Investigator, Project Manager, Clinical 
Research Coordinator, Clinical Trial Assistant, Research Nurse, Phlebotomist) who are in contact with 
Participants are responsible for collecting AE information from the Participant at each scheduled site 
visit or during telephone calls with the Participant. Therefore, Sponsor clinical research personnel or 
a delegate (e.g. CRO) who initiate and monitor the study are responsible for explaining the procedures 
for reporting and evaluating AEs to the PI or Sub-Investigator and all study personnel who come in 
contact with the Participants  
 
During the course of the study, complete reports of all AEs will be entered in the Participants site 
source documents, and if applicable, on the appropriate study case report forms (CRFs). 
 
A licensed clinician will be responsible for:  
- 
identifying and evaluating the severity (mild, moderate, or severe) and clinical importance of 
the AE,  
- 
taking appropriate medical action(s), and for  
- 
notifying the Sponsor immediately of an SAE as specified in the protocol and for notifying the 
Science Department for reporting to the IRB/IEC. 
 
Likewise, a licensed clinician will indicate the causality (relationship) of the AE to the Study Product 
and modify IP consumption in the event of a safety concern. 
 
For any laboratory abnormality, the PI or Sub-Investigator will make a judgement as to its clinical 
significance. If the laboratory value is thought to be clinically significant, the Sponsor may be consulted, 
and an assessment will be made by the PI or Sub-Investigator as to its relationship to Study Product 
administration and it will be documented on the AE page of the CRF.  

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The PI or Sub-Investigator will comply with applicable regulatory requirement(s) related to the 
reporting of SAEs to the IRB/IEC. 
 
The Monitor(s) will review completed CRF data and will compare CRF entries with information 
recorded in the source documents. Any discrepancies or omissions in either data source will be 
discussed with the site personnel who should make the appropriate corrections to the documents.  
 
The CRO will report all SAEs to the Sponsor within 24 hours of becoming aware of the event, whether 
or not the SAE is considered to be related to the Study Product. All clinically relevant SAEs will be 
reported to the Clinical Research Ethics Committee of the Cork Teaching Hospitals. 
12 Ethical Considerations 
12.1 Local Regulations and Declaration of Helsinki 
The PI/Sub-Investigator will ensure that this clinical study is conducted in line with the principles of 
the “Declaration of Helsinki” and/or with the laws and regulations of the country in which the research 
is conducted, whichever affords the greater protection to the individual.  
 
The site, investigator, protocol, informed consent form and any other pertinent documents for this 
study will be approved by the IRB. 
 
The study will not begin until the IRB has approved of the protocol and the Participant consent form 
along with any advertisements, diaries, and instructions to the Participants, if applicable. The IRB 
approval will be documented in writing to the PI/Sub-Investigator. 
 
12.2 GCP Management Directive  
The PI/Sub-Investigator will ensure that this clinical study is conducted in line with the principles of 
GCP, as outlined below:  
- 
Clinical studies should be conducted in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, and that are consistent with the principles of GCP (where 
applicable) and the applicable laws and regulatory requirements governing the conduct of 
human studies. 
- 
Foreseeable risks and inconveniences should be weighed against the anticipated benefit for 
the individual trial Participant and the society. 
- 
The rights, safety, and well-being of the Participants involved in clinical studies are the most 
important considerations and should prevail over interests of science and society. 
- 
The available nonclinical and clinical information on any Study Product should be adequate to 
support the proposed clinical trial. 
- 
Clinical studies should be scientifically sound, and described in a clear, detailed protocol. 
- 
Clinical studies should be conducted in compliance with the protocol that has received prior 
institutional review board (IRB)/independent ethics committee (IEC) approval/favorable 
opinion. 

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The medical care given to, and medical decisions made on behalf of, Participants involved in 
clinical studies should always be the responsibility of a qualified licensed clinician. 
- 
Each individual involved in conducting clinical studies should be qualified by education, 
training, and experience to perform his or her respective task(s). 
- 
Freely given written informed consent should be obtained from every Participant prior to 
participation in a clinical trial. 
- 
All information from clinical studies should be recorded, handled, and stored in a way that 
allows its accurate reporting, interpretation, and verification. 
- 
The confidentiality of records that could identify Participants should be protected, respecting 
the privacy and confidentiality rules in accordance with the applicable laws and regulatory 
requirements. 
- 
Study Product should be manufactured, handled, and stored in accordance with Morinaga 
Milk Industry quality standards, or if applicable, good manufacturing practice (GMP); IP(s) 
should be used in accordance with the approved protocol. 
- 
Systems with processes and procedures (such as SOPs) that assure the quality of every aspect 
of clinical studies should be implemented. 
 
12.3 Informed Consent 
It is the responsibility of the PI, or a person designated by the PI (if acceptable by local regulations), to 
obtain written informed consent from each Participant involved in this clinical study, or from the 
Participant’s legally acceptable representative, after adequate explanation of the aims, methods, 
anticipated benefits, and potential hazards of the study. No study procedures may be performed prior 
to obtaining the informed consent. The PI or Designee must also explain that the Participants are 
completely free to refuse to enter the study or to withdraw from it at any time, for any reason.  
 
12.4 IRB/IEC approval 
This protocol and any accompanying material provided to the Participant (such as Participant 
information leaflets or descriptions of the study used to obtain informed consent) as well as any 
advertising or compensation given to the Participants, will be submitted by the PI/Sub-Investigator to 
an IRB/IEC. Approval from the IRB/IEC will be obtained before starting the study and should be 
documented in a letter to the PI/Sub-Investigator specifying the date on which the IRB/IEC met and 
granted the approval. 
 
Any modifications (amendments) made to the protocol after receipt of the IRB/IEC approval must also 
be submitted by the PI/Sub-Investigator to the IRB/IEC in accordance with local procedures and 
regulatory requirements. 
 
12.5 Changes to Protocol  
Any changes to the protocol will be in the form of a written protocol amendment or note to file that 
will be issued by the Sponsor or designee.  
 
All amendments to the approved protocol require approval by the IRB/IEC. 

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The protocol requirements should in no way prevent any immediate action from being taken by the 
PI/Sub-Investigator, or by the Sponsor (or designee), in the interest of preserving the safety of the 
Participants included in the study.   
 
12.6 Protocol Adherence  
It is the responsibility of the PIs to apply due diligence to avoid protocol deviations. The Sponsor may 
be consulted if protocol deviations are identified, to determine the best course of action to protect 
Participant safety and maintain the integrity of the study data. All protocol deviations will be recorded 
in the Participants eCRF and reported in the clinical study report. 
13 Confidentiality 
13.1 Data 
All information regarding the nature of the proposed investigation provided by the Sponsor or its 
designee to the PI/Sub-Investigator (with the exception of information required by law or regulations 
to be disclosed to the IRB/IEC, the Participant, or the appropriate regulatory authority) must be kept 
in confidence by the PI/Sub-Investigator in accordance with all applicable laws and regulations as 
specified in the Clinical Trial Agreement.  
 
13.2 Participant Pseudonymity 
The pseudonymity of Participants must be maintained. Participants will be identified by an assigned 
Participant number on CRFs, and other documents submitted to the Sponsor or its designee.  
Documents that will not be submitted to the Sponsor or its designee and that identify the Participant 
(e.g., the signed informed consent document) must be maintained in strict confidence by the PI or 
designee, except to the extent necessary to allow auditing by the appropriate regulatory authority, 
the Sponsor, or its designee and in accordance with applicable regulatory requirements. 
 
13.3 Participants’ compensation / remuneration 
Participants will receive compensation for completing the study to cover costs and expenses – details 
are specified in Section 6 Study Procedures. 
 
14 Study Documentation and Record Keeping  
14.1 Protocol amendments 
Any modification to the agreed protocol must be approved in writing by both the Sponsor and the 
Investigator(s). Amendments will be submitted to the IRB/IEC, as required. These procedures must be 
fulfilled before any modification is put into effect.  
 
14.2 Investigator Site File 
The investigator must maintain adequate and accurate records to enable the conduct of the study to 
be fully documented and the study data to be subsequently verified. These documents should be 
classified into two different separate categories (1) Investigator's Site File (ISF), and (2) source 
documents. 
 

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The ISF will contain the protocol/amendments, CRFs, and Query Forms, IRB/IEC and governmental 
approval with correspondence, sample informed consent, staff curriculum vitae and authorization 
forms and other appropriate documents/correspondence etc. 
 
Source documents (usually defined by the project in advance to record key efficacy/safety parameters 
independent of the CRFs) would include Participants’ records, progress notes, appointment book, 
original laboratory reports, ECG, EEG, X-ray, pathology, and special assessment reports, signed 
informed consent forms, consultant letters, and Participant screening and enrolment logs.  
 
The investigator should retain the study documents of the ISF for the retention time specified in the 
contract with the Sponsor.  
 
Should the investigator wish to assign the study records to another party or move them to another 
location, the Sponsor must be notified in advance. 
 
If the investigator cannot guarantee this archiving requirement at the study site for any or all of the 
documents, special arrangements must be made between the investigator and the Sponsor to store 
these in a sealed container(s) outside of the site so that they can be returned sealed to the investigator 
in case of a regulatory audit. Where source documents are required for the continued care of the 
Participant, appropriate copies should be made for storing outside the site. 
 
14.2.1 Source document and source data verification 
According to the standards of the data protection law, all data obtained in the course of a clinical study 
must be treated with discretion in order to guarantee the rights of the Participant's privacy. The 
investigator should agree to allow the monitor/auditor/inspector to have access to any or all the 
clinical study materials needed for source data verification and proper review of the clinical study 
progress.  
15 Monitoring 
It is understood that the responsible monitor will contact and visit the clinical site regularly and will 
be allowed, on request, to review the various records of the study (CRFs/eCRFs and other pertinent 
data) provided that Participant confidentiality is maintained in accordance with local requirements 
and as specified in the contract. 
 
The Principal Investigator or designee at the site of the investigation will be instructed by the monitor 
to ensure that the following responsibilities and tasks are carried out: 
 
- 
Monitoring the study supplies and, if requested, returning all undispensed supplies to the 
Sponsor at completion of the study.   
- 
Maintaining all records of the study.  
- 
Checking source documents for legibility and completion at the time they are received from 
the clinical research team. After review of study data with Data Management, the PM, and 
clinical study team will ensure completeness of the CRF/eCRF. 
- 
Contacting Participants to remind them of their scheduled visits and obtaining a final 
disposition for every Participant who is entered in the study. 

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Checking for reasonableness and completeness of source documents and of recorded CRF 
data before CRFs are reviewed by a Sponsor monitor at each routine monitoring visit. 
 
It will be the monitor's responsibility to review the study documents (e.g., CRFs) at regular intervals 
throughout the study, to verify the adherence to the protocol and the legibility, completeness, 
consistency, and accuracy of the data being entered on them. The monitor must have access to 
laboratory test reports and other Participant records needed to verify the entries on the CRF/eCRF. 
This source data verification may be carried out remotely. 
 
The investigator (or his/her deputy) facilitates the monitoring tasks including the source document 
verification and agrees to cooperate with the monitor to ensure that any issues detected in the course 
of these monitoring visits are resolved. 
 
15.1 Quality assurance and quality control 
All SP used in clinical studies are subjected to quality control. Quality assurance audits may be 
performed by the Sponsor (or any health authority) during the course of the clinical study or after its 
completion (see Archiving).  
 
The PI/Sub-Investigator agrees to comply with Sponsor and regulatory requirements in terms of 
auditing of the clinical study. This includes access to the source documents for source data verification. 
16 Final Study Report 
When all completed CRFs have been collected and data have been analyzed, the results of this clinical 
study are to be documented in a Final Study Report as specified in the contract. 
17 Archiving 
The study documents will be retained for seven years after the completion of a clinical study. A clinical 
study is completed with the acceptance of the Final Study Report.  
 
The Trial Master File (TMF) shall be retained for a longer period, where so required by other applicable 
legal or regulatory requirements and/or as specified in the contract between the Sponsor and the 
PI/Sub-Investigator. 
18 References 
1. 
Wen Y, Li J, Long Q, Yue CC, He B, Tang XG. The efficacy and safety of probiotics for patients 
with constipation-predominant irritable bowel syndrome: A systematic review and meta-
analysis based on seventeen randomized controlled trials. Int J Surg. 2020 Jul;79:111-119. 
doi: 10.1016/j.ijsu.2020.04.063. Epub 2020 May 6. PMID: 32387213. 
4. 
Kondo J, Xiao JZ, Shirahata A, Baba M, Abe A, Ogawa K, Shimoda T. Modulatory effects of 
Bifidobacterium longum B. LONGUM on defecation in elderly patients receiving enteral 
feeding. World J Gastroenterol. 2013;19(14):2162-70. doi: 10.3748/wjg.v19.i14.2162. PMID: 
23599642; PMCID: PMC3627880. 
 

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