Exploratory Study in Healthy Volunteers to Define Circadian Relationships Between Social Behavior, Blood Pressure and Metabolomics
Conditions: Healthy
Sponsor: University of Pennsylvania

Human Circadian Rhythmicity 
 
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CLINICAL RESEARCH PROTOCOL 
 
 
 
 
EXPLORATORY PHASE I STUDY IN HEALTHY VOLUNTEERS 
TO DEFINE CIRCADIAN RELATIONSHIPS BETWEEN SOCIAL 
BEHAVIOR, 
BLOOD 
PRESSURE 
AND 
METABOLOMIC 
SIGNATURES. 
 
Principal Investigators 
(Regulatory Sponsors): 
Carsten Skarke, MD 
Institute for Translational Medicine and Therapeutics (ITMAT),  
8036 Maloney Bldg., 3600 Spruce St 
Philadelphia, Pennsylvania 19104 
Phone: 215-746-8330 
 
Co-Principal Investigators 
(Regulatory Sponsors): 
Aalim Weljie, PhD 
Institute for Translational Medicine and Therapeutics (ITMAT),  
Department of Pharmacology,  
University of Pennsylvania Perelman School of Medicine,  
3400 Civic Center Boulevard, Building 421, 10th Floor  
Phone: 215-573-8085 
 
Admitting 
Physician 
/ 
Funding Sponsor: 
Garret A. FitzGerald, MD 
 
Institute for Translational Medicine and Therapeutics (ITMAT), 
Department of Pharmacology,  
University of Pennsylvania Perelman School of Medicine,  
3400 Civic Center Boulevard, Building 421, 10th Floor 
Phone: 215-898-1184 
 
Study Product: 
None 
Protocol Number: 
IRB # 817759 
IND Number: 
Not applicable 
Short Title: 
Human Circadian Rhythmicity 
 
 
Initial version: March 11, 2013 
Revised version: June 25, 2013 and July 12, 2013 
Amended: February 3, 2014 
Amended: February 19, 2014 
Amended: March 3, 2014 
Amended: July 11, 2014 
 

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Table of Contents 
 
STUDY SUMMARY .................................................................................................................................... 10 
1 
INTRODUCTION ............................................................................................................................... 11 
1.1 
BACKGROUND .................................................................................................................................. 11 
1.2 
INVESTIGATIONAL AGENT .................................................................................................................. 12 
1.3 
CLINICAL DATA TO DATE................................................................................................................... 12 
2 
STUDY OBJECTIVES ........................................................................................................................ 13 
2.1 
PRIMARY OBJECTIVE ......................................................................................................................... 13 
2.2 
SECONDARY OBJECTIVE ..................................................................................................................... 13 
3 
STUDY DESIGN ................................................................................................................................. 14 
3.1 
GENERAL DESIGN ............................................................................................................................. 14 
3.2 
PRIMARY STUDY ENDPOINTS .............................................................................................................. 14 
3.3 
SECONDARY STUDY ENDPOINTS ......................................................................................................... 14 
3.4 
PRIMARY SAFETY ENDPOINTS ............................................................................................................ 14 
4 
SUBJECT SELECTION AND WITHDRAWAL ................................................................................. 14 
4.1 
INCLUSION CRITERIA ......................................................................................................................... 14 
4.2 
EXCLUSION CRITERIA ........................................................................................................................ 15 
4.3 
SUBJECT RECRUITMENT AND SCREENING ............................................................................................. 15 
4.4 
EARLY WITHDRAWAL OF SUBJECTS .................................................................................................... 15 
4.4.1 
When and How to Withdraw Subjects ........................................................................................ 15 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects .............................................................. 15 
5 
STUDY DRUG .................................................................................................................................... 16 
6 
STUDY PROCEDURES ...................................................................................................................... 16 
6.1 
MEDICAL HISTORY / PHYSICAL ........................................................................................................... 16 
6.2 
ROUTINE LABORATORY SCREENS ........................................................................................................ 16 
6.3 
LABORATORY SCREENS FOR COMPLIANCE ............................................................................................ 16 
6.3.1 
Platelet aggregation .............................................................................................................. 16 
6.3.2 
Cotinine ................................................................................................................................. 16 
6.3.3 
Protocol Non-Conform Drugs ................................................................................................ 16 
6.3.4 
Pregnancy test....................................................................................................................... 16 
6.4 
QUESTIONNAIRES .............................................................................................................................. 17 
6.4.1 
Food frequency questionnaire ............................................................................................... 17 
6.4.2 
International Physical Activity Questionnaire ........................................................................ 17 
6.4.3 
Recall Diary ........................................................................................................................... 18 
6.4.4 
Dietary assessment using smartphone applications ............... Error! Bookmark not defined. 
6.4.5 
Chronotype Questionnaire ........................................................................................................ 18 
6.5 
URINE COLLECTIONS FOR METABOLOMICS ANALYSES .......................................................................... 19 
6.6 
BLOOD COLLECTIONS FOR METABOLOMICS ANALYSES ......................................................................... 20 
6.7 
SALIVA COLLECTIONS FOR METABOLOMICS ANALYSES ........................................................................ 20 
6.8 
BLOOD COLLECTIONS FOR TRANSCRIPTOMICS ANALYSES ..................................................................... 20 
6.9 
MOUTHS SWABS FOR MICROBIOME ANALYSES .................................................................................... 20 
6.10 
FECAL SWABS FOR MICROBIOME ANALYSES ................................................................................... 21 
6.11 
STOOL SAMPLES FOR MICROBIOME ANALYSES ................................................................................ 21 
6.12 
WATER INTAKE ............................................................................................................................ 21 
6.13 
VITAL SIGNS ................................................................................................................................ 21 
6.14 
SOCIAL SENSING TECHNOLOGY ...................................................................................................... 21 
6.14.1 
Data Collection (through Mobile Phone) and Transmission .................................................... 22 
6.14.2 
Data Storage, Encryption and Server Security........................................................................ 22 

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6.14.3 
Data Access (through Web Dashboard) ................................................................................. 23 
6.14.4 
HIPAA Compliance ............................................................................................................. 23 
6.14.5 
Backups .............................................................................................................................. 23 
6.14.6 
Ginger.io Privacy Philosophy ............................................................................................... 24 
6.14.7 
Set-up and removal of the Ginger.io smartphone application ................................................... 24 
6.14.8 
Potential Risks and Discomforts ............................................................................................ 24 
6.15 
ACTIGRAPHY ................................................................................................................................ 25 
6.16 
AMBULATORY BLOOD PRESSURE MONITORING (ABPM) .................................................................. 25 
6.17 
METABOLOMICS ........................................................................................................................... 26 
6.18 
TRANSCRIPTOMICS ........................................................................................................................ 26 
6.19 
GENETIC ANALYSES ...................................................................................................................... 27 
6.20 
MICROBIOME ANALYSES ............................................................................................................... 27 
6.21 
ADDITIONAL ANALYSES ................................................................................................................ 28 
6.22 
CLINICAL STUDY VISITS ................................................................................................................ 28 
6.22.1 
Screening Visit .................................................................................................................... 28 
6.22.2 
Ginger.io Set-up Visit (Visit V1) ............................................................................................ 29 
6.22.3 
Brief Visits to exchange batteries in actigraphy device (Visit V2, V3 and V12) .......................... 29 
6.22.4 
Preparatory Visits (Visit V4 and V8) ..................................................................................... 29 
6.22.5 
Assessment Visits – Day 1 (Visit V5 and V9) .......................................................................... 30 
6.22.6 
Assessment Visits – Day 2 (Visit V6 and V10) ......................................................................... 30 
6.22.7 
Assessment Visits – Day 3 (Visit V7 and V11) ......................................................................... 31 
6.22.8 
Exit Visit (Visit V13) ............................................................................................................ 31 
7 
STATISTICAL PLAN ......................................................................................................................... 32 
7.1 
SAMPLE SIZE DETERMINATION ........................................................................................................... 32 
7.2 
STATISTICAL METHODS ..................................................................................................................... 32 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ............................................................................................. 33 
8 
SAFETY AND ADVERSE EVENTS ................................................................................................... 33 
8.1 
DEFINITIONS ..................................................................................................................................... 33 
8.2 
RECORDING OF ADVERSE EVENTS ....................................................................................................... 35 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .......................................... 35 
8.3.1 
Investigator reporting: notifying the Penn IRB ........................................................................... 36 
8.4 
REPORTING OF ANY BREACHES OF CONFIDENTIALITY TO THE GINGER.IO SYSTEM ..................................... 36 
8.5 
STOPPING RULES ............................................................................................................................... 37 
8.6 
MEDICAL MONITORING ..................................................................................................................... 37 
9 
DATA HANDLING AND RECORD KEEPING .................................................................................. 37 
9.1 
CONFIDENTIALITY ............................................................................................................................. 37 
9.2 
SOURCE DOCUMENTS ........................................................................................................................ 38 
9.3 
CASE REPORT FORMS ........................................................................................................................ 38 
9.4 
DATA MANAGEMENT......................................................................................................................... 38 
9.5 
RECORDS RETENTION ........................................................................................................................ 38 
9.6 
DATA HANDLING, RECORD KEEPING, AND CONFIDENTIALITY IN RELATION TO THE GINGER.IO SMARTPHONE 
APPLICATION ............................................................................................................................................. 38 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................ 39 
10.1 
STUDY MONITORING PLAN ............................................................................................................ 39 
10.2 
AUDITING AND INSPECTING ........................................................................................................... 39 
11 
ETHICAL CONSIDERATIONS ......................................................................................................... 39 
12 
STUDY FINANCES ............................................................................................................................ 39 
12.1 
FUNDING SOURCE ......................................................................................................................... 39 
12.2 
CONFLICT OF INTEREST ................................................................................................................. 40 
12.3 
SUBJECT PAYMENTS ...................................................................................................................... 40 

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13 
MASTER LICENSE AGREEMENT ................................................................................................... 40 
14 
SECURITY AND PRIVACY INFORMATION IMPACT ASSESSMENT .......................................... 40 
15 
PUBLICATION PLAN ....................................................................................................................... 40 
16 
TRIAL REGISTRATION ................................................................................................................... 40 
17 
REFERENCES ................................................................................................................................... 40 
18 
APPENDIX ........................................................................................................................................... 1 
18.1 
STUDY FLOW-CHART ...................................................................................................................... 1 
18.2 
BLOOD SAMPLE SCHEDULE .............................................................................................................. 3 
18.3 
HOUR INTERVALS VERSUS 24-HOUR CLOCK ....................................................................................... 0 
18.4 
HEALTH QUESTIONNAIRE ................................................................................................................ 1 
18.5 
FLYER FOR SUBJECT RECRUITMENT ................................................................................................... 7 
18.6 
PHYSICAL ACTIVITY QUESTIONNAIRE ............................................................................................... 8 
18.7 
TEMPLATE MEDICAL MONITORING ................................................................................................. 15 
18.8 
SAMPLE SUBJECT DIARY RECALL FORM .......................................................................................... 18 
18.9 
MUNICH CHRONOTYPE QUESTIONNAIRE (MCTQ) ........................................................................... 20 
18.10 
NO-REVISIONS LETTER – SECURITY AND PRIVACY IMPACT ASSESSMENT ........................................... 22 
18.11 
SECURITY AND PRIVACY INFORMATION IMPACT ASSESSMENT (SPIA) ................................................ 23 
18.12 
SURVEYS DELIVERED THROUGH THE SMARTPHONE APP GINGER.IO ..................................................... 27 
18.12.1 
Ginger.io Demographic Questionnaire (only at download) ............................................... 27 
18.12.2 
Ginger.io Sleep Questionnaire (daily in the morning) ....................................................... 27 
18.12.3 
Ginger.io App Satisfaction Questionnaire (only at completion) ........................................ 27 
 
 

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List of Abbreviations and Definitions 
 
ABPM: Ambulatory blood pressure monitoring. 
Active Data Collection: Refers to data collection dependent on explicit user input.  
BP: Blood pressure. 
Background Process: Refers to an operating system service that allows an application to 
perform an operation without interacting with the user or disrupting other applications.  
GBI (Ginger.io Behavior Index): Refers to a set of features (or variables) used by the 
Ginger.io platform to gather health insights and make inferences.  
Ginger.io Behavior Platform: Refers to the mobile application (or app) and the web 
dashboard.  
Mobile Application: Refers to the application installed on the users’ phones that allows for 
data collection. This application includes two components: (1) a background process that is 
launched automatically by the application (after initial installation and user log-­‐on) to gather 
data unobtrusively (2) a front end mobile user interface with a survey component that allows 
the users to receive and submit surveys.  
Notification: Refers to an operating system service that allows an application to display a 
message to the patient to grab their attention.  
Passive Data Collection: Refers to data collection from the users’ devices without any effort 
from them.  
Web Dashboard: Refers to a web-­‐based study management system that allows investigators 
and study staff to monitor the data collection process (including passive data collection and 
survey completion), identify issues and analyze the data.  
 
 

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RESPONSIBILITIES AND SIGNATURES 
The responsibilities and signatures below constitute the approval of this protocol, its attachments 
and amendments, and provide the necessary assurances that this trial will be conducted according 
to all stipulations of the protocol, including all statements regarding confidentiality, and 
according to local legal and regulatory requirements and applicable US federal regulations and 
ICH guidelines. 
 
 
Principal Investigator:  
 
Signed: 
 
 
Date: 
March 11, 2013 
 
Name: Carsten Skarke 
Title: MD 
 
 
 
Address: 
Institute for Translational Medicine and Therapeutics (ITMAT), 
University of Pennsylvania School of Medicine, 
8036 Maloney Bldg. 
3600 Spruce St 
University of Pennsylvania, 
Philadelphia, Pennsylvania 19104 
Telephone: 215.746.8330 
Fax: 215. 573.8996 
 
e-mail: 
cskarke@mail.med.upenn.edu  
 
Co- Principal Investigator:  
 
Signed: 
 
 
Date: 
March 11, 2013 
 
Name: Aalim Weljie 
Title: PhD 
 
 
 
Address: 
Department of Pharmacology 
Institute for Translational Medicine and Therapeutics 
Translational Research Center 
3400 Civic Center Boulevard, Building 421 
10th Floor, Room 10-113 
Philadelphia, PA  19104-5158 
Telephone: 215-573-8085 
Fax: 215-573-9135 
 
e-mail: aalim@upenn.edu 
 
 
 

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Other Investigators: 
 
Title: 
Contact Information: 
Responsibilities: 
Lavenia Banas 
R.N. 
8037 Maloney Bldg 
Hospital of the University of 
Pennsylvania 
3600 Spruce Street 
Philadelphia, PA 19104 
Phone: 215-662-4652 
Fax: 215-573-8996 
e-mail: banas@itmat.upenn.edu  
Clinical Research 
Coordinator 
 
Lisa Basel-Brown 
MS, RD, LDN 
Translational Research Center 
Hospital of the University of 
Pennsylvania, 
1 Dulles Building, 
34th and Spruce Streets 
Philadelphia, PA 19104 
Phone: 215-662-7824 
Fax: 215-662-2643 
e-mail: lisa@spirit.gcrc.upenn.edu  
Research Nutritionist 
 
Susanne Fries 
MD 
8038 Maloney Bldg 
Hospital of the University of 
Pennsylvania 
3600 Spruce Street 
Philadelphia, PA 19104 
Phone: 215-746-8331 
Fax: 215-573-8996 
e-mail: fries@upenn.edu  
Medical Monitor 
John Lawson 
 
Department of Pharmacology, Institute for 
Translational Medicine and Therapeutics, 
Smilow Translational Research Center, 
3400 Civic Center Boulevard, Building 
421, 10th Floor, Room 10-115, 
Philadelphia, PA  19104-5158  
Phone: 215-573-7038 
e-mail: jalawson@mail.med.upenn.edu  
 
Lipidomics 
Carissa Fuller 
CRNP, MSN,  
Clinical & Translational Research Center 
Hospital of the University of 
Pennsylvania, 
1 Dulles Building, 
34th and Spruce Streets 
Philadelphia, PA 19104 
Phone: 215.349.8067 
Fax: 215-662-2643 
e-mail: Carissa.Fuller@uphs.upenn.edu  
 
Nurse Practitioner 
Kathleen J. 
Schumacher 
CRNP, MSN, 
ANP-BC 
Clinical & Translational Research Center 
Hospital of the University of 
Pennsylvania, 
1 Dulles Building, 
34th and Spruce Streets 
Philadelphia, PA 19104 
Phone: 215-662-7824 
Nurse Practitioner 

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Fax: 215-662-2643 
e-mail: kathlj@mail.med.upenn.edu  
 
Cheryl Milhoan 
MS, RD 
Clinical & Translational Research Center 
Hospital of the University of 
Pennsylvania, 
1 Dulles Building, 
34th and Spruce Streets 
Philadelphia, PA 19104 
Phone: 215-662-3180 
Fax: 215-662-2643 
e-mail: cheryl@spirit.gcrc.upenn.edu  
Research Nutritionist 
Lindsey Albenberg 
DO 
Fellow 
Division of Pediatric Gastroenterology, 
Hepatology, and Nutrition 
The Children's Hospital of Philadelphia 
Philadelphia, PA 19104 
e-mail: AlbenbergL@email.chop.edu 
Swab sampling technique 
Judith R Kelsen 
MD 
ASST PROFESSOR C-E, PE-Pediatrics 
Division of Pediatric Gastroenterology, 
Hepatology, and Nutrition 
The Children's Hospital of Philadelphia 
Philadelphia, PA 19104 
Phone: 215-363-9057  
e-mail: KELSEN@email.chop.edu 
Swab sampling technique 
Frederik Bushman 
PhD 
425 Johnson Pavilion  
3610 Hamilton Walk  
Philadelphia, PA 19104  
Office: (215) 573-8732 
Fax: (215) 573-4856  
e-mail: bushman@mail.med.upenn.edu 
Microbiome Studies 
Gregory Grant 
PhD 
Department of Pharmacology, 
Institute for Translational Medicine and 
Therapeutics, 
Smilow 
Translational 
Research Center, 3400 Civic Center 
Boulevard, Building 421, 10th Floor 
Philadelphia, PA  19104-5158 
Office: (215)-898-3736 
e-mail: ggrant@pcbi.upenn.edu   
Statistical Analyses 
Thomas S.  Price 
PhD 
Department of Pharmacology, 
Institute for Translational Medicine and 
Therapeutics, 
Smilow 
Translational 
Research Center, 3400 Civic Center 
Boulevard, Building 421, 10th Floor 
Philadelphia, PA  19104-5158 
Office: (215)-898-1189 
e-mail: tsprice@mail.med.upenn.edu  
Statistical Analyses 
Seth Rhoades 
 
Department of Pharmacology, 
Institute for Translational Medicine and 
Therapeutics, 
Smilow 
Translational 
Research Center, 3400 Civic Center 
Boulevard, Building 421, 10th Floor 
Philadelphia, PA  19104-5158 
e-mail: srhoades@mail.med.upenn.edu   
Metabolomics 
 
 

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Annie Curtis, PhD 
 
Inflammation Research Group 
Trinity Biomedical Science Institute 
(TBSI) 
152-160 Pearse Street 
Trinity College Dublin 
Ireland 
Ph: 353-1-8962449   
Transcriptomics Analysis 
 
 

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Study Summary 
Title 
Exploratory study in healthy volunteers to define circadian 
relationships between social behavior, blood pressure and urine 
metabolomics. 
Short Title 
Human Circadian Rhythmicity 
Protocol Number 
IRB number 817759 
Phase 
Clinical study Phase 1 
Methodology 
Single-arm study design  
Study Duration 
Between ¾ - 1 year 
Study Center(s) 
Single-center  
Objectives 
1) Can the social sensing technology be implemented to explore 
relationships between patterns of user activity, blood pressure and 
metabolic signatures? 2) To assess the circadian variation over 
time for each parameter individually. 3) Can the difference in 
assessment frequency – unscheduled and random for user activity 
versus scheduled and timed for blood pressure and metabolites – 
be integrated to recognize individual circadian patterns? 4) To 
assess the circadian co-variation over time between user activity, 
blood pressure and metabolic signatures.  
Age 
25-35 years of age 
Number of Subjects 
n=6 
Diagnosis 
and 
Main 
Inclusion Criteria 
Healthy male volunteers if feasible during recruitment. Key 
inclusion criteria: 25-35years of age, own a smartphone (Android 
phones only) which installs the social sensing application 
ginger.io   
Study 
Product, 
Dose, 
Route, Regimen 
None included 
Duration 
of 
administration 
Not applicable 
Reference therapy 
None included 
Statistical Methodology 
Standard summary statistics; exploring the shape of the curves 
over time; identifying peaks and troughs. 
 

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1 
Introduction 
This document is a protocol for a human research study. This study is to be conducted according 
to US and international standards of Good Clinical Practice (FDA Title 21 part 312 and 
International Conference on Harmonization guidelines), applicable government regulations and 
Institutional research policies and procedures.  
1.1 
Background 
Smartphones represent a rich source for user activity data.  These social sensing data can be 
mined to identify patterns of social behavior. Changes therein enable researchers to make 
inferences about the health status of individuals, e.g. the decrease of social interactions during 
acute flu outbreaks.  
 
We wish to test in a small pilot study in healthy volunteers whether this social sensing 
technology can be implemented to explore relationships between circadian patterns of user 
activity, continuous blood pressure and metabolic signatures in urine samples.  
 
The social sensing technology might provide insight how to integrate quantitatively social 
behavior into exploring cardiovascular and metabolic functions influenced by the molecular 
clock.  
 
Blood pressure can easily be monitored as cardiovascular biomarker in healthy volunteers. 
Circadian variations in blood pressure are well studied in humans. Blood pressure levels in 
healthy humans vary considerably over the course of a day. Prominent is the steep increase in 
blood pressure during early morning hours, which gradually decreases throughout the day to 
reach the lowest levels during nighttime sleep. Here, the mean blood pressure readings from 
waking versus sleeping hours can differ up to 10-20%. Alterations to this circadian rhythmicity 
in blood pressure are commonly seen among patients with cardiovascular diseases. The ‘dipping’ 
phenotype – the substantial decrease in blood pressure during sleeping hours – may change to a 
‘non-dipping’ phenotype – the absence of such a drop in blood pressure. This blood pressure 
characteristic is strongly related to cardiovascular health, e.g. some patients who lack such a 
nocturnal dip are at increased risk of developing hypertension which in turn often results in end 
organ damage. The incidence of cardiovascular events in humans has a marked temporal 
component, such that myocardial ischemia, myocardial infarction, sudden cardiac death, and 
stroke typically occur in the early morning hours. Above is reviewed in (1-3). A mechanism to 
consider for these diseases is that environmental cues and behavioral patterns desynchronize 
body functions. This notion is supported by the recent proposition that an endogenous circadian 
rhythm causes the blood pressure to peak in the evening at around 9 pm (4).  
 
Metabolomics is becoming a powerful technical approach to assess circadian patterns of 
metabolomics function in small numbers of participants. Forced de-synchronization or highly 
standardized protocols in humans revealed that a substantial number of metabolites follow an 
circadian rhythm, up to 15% in a cohort of n=10 age-matched male subjects (5) and up to 19% in 
n=8 male volunteers (6). Recently, a timetable of oscillating metabolites has been proposed for 
the human organism (7). Still a challenge in metabolomics, however, is the variation in noise-
versus-signal ratio across different biofluids (8). Dense circadian profiling of the urine 
metabolome (9) will be enriched with metabolomics data from blood and saliva (10) samples at 

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selected ‘anti-phase’ sampling times. A recent study in humans proposed that a few samples 
collected in ‘anti-phase’ can determine internal body time in humans (7), a concept developed 
earlier in mice (11). Furthermore, the relationship between circadian metabolome and 
transcriptome will be explored as recent evidence suggested that the hepatic circadian clock 
drives nucleotide synthesis and degradation (12). 
 
Dietary intake influences social behavior, circadian rhythms, metabolites and gene expression. 
Therefore, several instruments to assess dietary intake will be implemented. In addition to the 
classic instruments such as food frequency questionnaire, innovative approaches via smartphone 
application will be used as well. To meet the challenge that even nutrition professionals 
underreport dietary intake in dietary instruments (13), metabolomics will be explored as a 
strategy to quantify food intake. For example, enterolactone concentrations reflect intake of 
whole-grain foods (14); concentrations of δ15N reflect that of fish foods (15). 
  
We have preliminary data from healthy humans that suggest that the composition of the gut 
bacteria follows a circadian pattern (Carsten Skarke, unpublished observation). Translational 
studies in humans will rely on study paradigms based on frequent stool sampling techniques not 
yet in place. Therefore, this protocol includes collecting microbiota by sampling non-invasively 
the mucosa in the mouth (mouth swabs) as well as in the distal rectum (fecal swabs). This will 
provide first data on the feasibility of these two frequent sampling techniques.  
 
To limit variability in this pilot data set, the age range for inclusion into the study will be set to 
25-35 years of age. Also, male subjects only will be enrolled at this stage of the project, provided 
this strategy is feasible during the recruitment phase. Otherwise female volunteers will be invited 
to the study. The menstrual cycle, a supradian rhythm, influences many biological processes in a 
woman’s body, which adds variability to the outcome data, particularly if women are studied at 
different stages of their menstrual cycle. 
 
1.2 
Investigational Agent 
None applied in this study. 
1.3 
Clinical Data to Date 
Clinical data to date exists predominantly in the domain of using behavioral patterns, or the 
change in these, as a predictor of human health or its transition to disease.  
 
Previous research, conducted and compiled by members of the Ginger.io team, has 
concluded that health-related behavior data from smart phones is predictive of behaviors 
associated with health outcomes. Described below are three specific examples:  
●    Common Colds, Influenza, and Stress (16) 
In a study involving 80 participants over 3 months using an earlier version of the smart phone 
app, Ginger.io found that statistical features extracted from phone call data records, SMS 
records, and movement logs for individuals showed statistically significant differences on the 
days the person was symptomatic, versus the days that the person was healthy. By designing 
a Bayesian classifier with 4-­‐fold cross-validation based on these behavior features, it was 
possible to identify symptomatic days with a recall of 0.6 – 0.9 for different clusters of 
symptoms. The symptoms data was collected using mobile phone surveys.  

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●    Chronic Inflammatory Bowel Disease (IBD) 
In an ongoing study with a leading hospital provider, the Ginger.io mobile platform is being 
used to understand what behavior changes are correlated with flare-­‐ups of Chronic 
Inflammatory Bowel Disease (IBD). Clinical investigators are testing an important 
hypotheses – are stress and IBD flare-­‐ups correlated? A better understanding of the 
relationship between stress and IBD symptoms can help design tools for early detection and 
strategies for patients to better manage their condition.  
●    Obesity and Long-­‐term Weight Gain (17) 
An ongoing debate in public policy considers whether unhealthy diet and exercise habits 
resulting in obesity are “contagious”. A study using a previous version of the Ginger.io 
platform and involving 70 co-located participants over a 6 months, attempted to find links 
between social exposure to obese and unhealthy individuals and their reported weight 
changes. It was found that weight changes amongst participants were weakly correlated with 
exposure to those previously obese or overweight. Further, weight changes amongst 
participants in the same period were strongly associated with exposure to others that gained 
weight in the same period.  
2 
Study Objectives 
Based on previous pilot studies by Ginger.io, we expect acceptance for the social sensing 
technology among participants. 
2.1 
Primary Objective 
To determine the feasibility of the social sensing technology to identify circadian patterns in 
user activity and to determine its variation over time among healthy volunteers.   
Hypothesis:  
User activity follows a circadian rhythm among healthy volunteers.  
Question:  
Can we detect different ‘circadian phenotypes’ of social behavior among healthy volunteers? 
 
2.2 
Secondary Objective 
To identify circadian patterns in user activity, blood pressure and metabolomics signatures 
and to determine the variation over time among healthy volunteers.   
Hypothesis:  
Social behavior follows a circadian rhythm and correlates with circadian patterns in blood 
pressure and metabolomics signatures among healthy volunteers.  
Question:  
Can we link different ‘circadian phenotypes’ of social behavior to circadian patterns in blood 
pressure and metabolomics signatures among healthy volunteers? 
 
Further secondary objectives are to identify whether dietary and transcriptomic patterns 
influence circadian patterns in user activity, blood pressure and metabolomics signatures as 
well as in the microbiome; also, to determine the variation over time among healthy 
volunteers.   
 

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3 
Study Design 
3.1 
General Design 
Healthy participants (n=6) will be enrolled in this single-arm Phase I exploratory study. 
Procedures to obtain informed consent, to assess eligibility per inclusion and exclusion 
criteria and to conduct the screening clinic visit will be scheduled for the Clinical 
Translational Research Center (CTRC). Recruitment is facilitated by our database of healthy 
volunteers and targeted advertisement observing the NIH policy on inclusion of women and 
minorities in clinical research.  
First, baseline data for the user activity will be collected for the duration of a minimum of 
one month up to a maximum of two months (weeks 1-8). User activity will be continuously 
recorded for another two month (weeks 9-16), while ambulatory blood pressure (ABPM) 
will be monitored for the duration of 48 hours twice, i.e. in weeks 10 and 12. Simultaneously 
to the ABPM, metabolomics will be analyzed in weeks 10 and 12 in urine, blood and saliva 
samples. mRNA expression will be assessed in timed blood samples. Study close-out will be 
conducted in week 17 with exit safety labs. Thus, the expected duration of subject 
participation will be 16 weeks plus the time necessary for the screening and exit visits.  
 
 
3.2 
Primary Study Endpoints 
Circadian patterns in user activity and its variability will be identified by visual inspection 
and exploratory statistical analysis. 
3.3 
Secondary Study Endpoints 
Circadian patterns in user activity, blood pressure, metabolomics and microbiome signatures 
and its variability will be identified by visual inspection and exploratory statistical analysis. 
3.4 
Primary Safety Endpoints 
Screening and exit laboratory tests will serve as primary safety endpoints. 
4 
Subject Selection and Withdrawal 
4.1 
Inclusion Criteria 
• Volunteers must be in good health as based on medical history, physical examination, 
vital signs, and laboratory tests as deemed by PI; 
• Volunteers are capable of giving informed consent; 
• 25-35 years of age;  
Social Sensing
Enrollment
Informed 
Consent,
Screening,
Eligibility per 
Inclusion and 
Exclusion 
Criteria
(n=6)
Exit 
Visit
Social Sensing & Blood Pressure & Metabolomics
Social 
Sensing
Month -1
Month 2
48h 
ABPM
Month 1
Social Sensing Baseline
Study Design 
Week 9
Week 10
Week 11
Week 12
Month 4
48h 
ABPM
Metab
olomics
Metab
olomics
Close-Out
Week 17
Month 3

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• Own a smartphone (Android phones only) which installs the social sensing 
application ginger.io; 
• Non-smoking;  
• Male subjects only if feasible during recruitment; and 
• In case female volunteers are invited to enroll: non-pregnant, female subjects must 
consent to a urine pregnancy test. 
4.2 
Exclusion Criteria 
• Recent travel across time zones (within the past month); 
• Planned travel across time zones during the planned study activities; 
• Volunteers with irregular work hours, e.g. night shifts or becoming a parent.  
• Use of illicit drugs; 
• Subjects, who have received an experimental drug, used an experimental medical device 
within 30 days prior to screening, or who gave a blood donation of ≥ one pint within 8 
weeks prior to screening. 
• 
Subjects with any abnormal laboratory value or physical finding that according to the 
investigator may interfere with interpretation of the study results, be indicative of an 
underlying disease state, or compromise the safety of a potential subject.  
4.3 
Subject Recruitment and Screening 
Healthy volunteers will be recruited from the database of healthy volunteers in the Clinical 
and Translational Research Center (CTRC), through advertisement (flyer, postings on 
Craigslist 
at 
www.craigslist.org, 
and 
the 
online 
registry 
of 
volunteers 
at 
https://www.researchmatch.org/), and by word of mouth. These advertisements will be 
approved by the IRB for the site; a sample of such information is located in the attachment 
section of the protocol.   
4.4 
Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
All subjects are free to withdraw from participation in this study at any time, for any reason, and 
without prejudice. 
The Investigator may terminate a subject from the study at any time for intolerable or 
unacceptable 
AEs, 
intercurrent 
illness, 
noncompliance 
with 
protocol 
requirements, 
administrative reasons, or in the Investigator’s opinion to protect the subject’s best interest. 
If a subject is withdrawn before completing the study, the reason for withdrawal will be entered 
on the appropriate case report form (CRF). Whenever possible and reasonable, the evaluations 
which were to be conducted at the completion of the study should be performed at the time of 
premature discontinuation. 
 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
Whenever possible and reasonable, the evaluations which were to be conducted at the 
completion of the study should be performed at the time of premature discontinuation. To 
encourage subjects to participate in the end-of-study clinic visit, up to 10 contacts will be 
initiated via e-mail, text message or phone by study coordinators. If this fails to motivate the 
subject, up to 2 phone calls will be initiated by the PI, Co-PI, or qualified sub-investigator (MD). 
As next steps, phone call(s) to next-of-kin if available will be initiated and up to one certified 
letter will be sent to subjects in order to schedule the exit visit. 
 

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5 
Study Drug  
A study drug will not be administered. 
6 
Study Procedures 
6.1 
 Medical History / Physical 
The medical history and the physical exam will be taken in the CTRC by a nurse practitioner. 
6.2 
Routine laboratory screens 
Screening and exit laboratory screen will consist of: 
• Hematology (white blood cell count, red blood cell count, hemoglobin, hematocrit, MCV, 
MCH, MCHC, RCDW, and platelet count). 
• Serum chemistry (sodium, potassium, chloride, urea nitrogen, creatinine, fasting  glucose, 
albumin, alkaline phosphatase, fasting cholesterol, HDL cholesterol and LDL cholesterol, 
triglycerides, ALT, AST, LDH, total bilirubin, GGT, uric acid, and phosphate). 
• Urinalysis. 
6.3 
Laboratory screens for compliance 
6.3.1 Platelet aggregation 
Blood will be collected in Na-Citrate Tubes for aggregation testing. Platelet aggregation will be 
measured in platelet-rich plasma (PRP) by turbidometry, measuring the change in light 
transmission during platelet aggregation. Platelets will be stimulated by 20 µmol/L adenosine 
diphosphate (ADP) (18). Maximum aggregation and the maximum slope of the change in light 
transmission within 5 minutes post stimulation will be recorded. Additionally, maximum 
aggregation and slope of secondary aggregation responses will be recorded. On selected days 
after enrollment, platelet aggregation will be assessed to rule out recent NSAID use (19) by using 
one or more of the following agents: arachidonic acid (AA), collagen (Coll), thrombin-receptor 
activating peptide (TRAP) and ADP. 
6.3.2 Cotinine 
Urinary cotinine, the nicotine metabolite indicating recent tobacco or nicotine use, will be 
qualitatively assessed per One-Step Rapid Nicotine (COT) Test, Craig Medical Distribution, 
Inc., 1185 Park Center Drive, Vista, CA (or similar) . This immunoassay detects cotinine at a 
cut-off sensitivity level of 200 ng/ml.   
6.3.3 Protocol Non-Conform Drugs 
Urine will be used to assess intake of protocol non-conform drugs by means of the Rapid Detect 
10 Panel Test Dip Card, Rapid Detect, Inc., 804 South Broadway, Poteau, OK (or similar). The 
drug screen includes for example Amphetamines (AMP), cocaine (COC), Tetrahydrocannabinol 
(THC), methamphetamine (mAMP), opiates (OPI), Phencyclidine (PCP), benzodiazepines 
(BZO), tricyclic antidepressants (TCA), barbiturates (BAR), and methadone (MTD).   
6.3.4 Pregnancy test 
A standard pregnancy urine dip test will be used to rule out a pregnancy. 

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6.4 
Questionnaires 
6.4.1 Food questionnaires 
6.4.1.1 
3-day food record  
The 3-day food record will be collected and analyzed by using Nutrition Data System for 
Research (NDSR). 
6.4.1.2 
24-hour dietary recall 
The 24-hour dietary recalls will be collected using Nutrition Data System for Research (NDSR), 
a computer-based software application developed at the University of Minnesota Nutrition 
Coordinating Center (NCC) that facilitates the collection of recalls in a standardized fashion 
(20). Dietary intake data gathered by interview is governed by a multiple-pass interview 
approach (21). Five distinct passes provide multiple opportunities for the participant to recall 
food intake. The first pass involves obtaining from the participant a listing of all foods and 
beverages consumed in the previous 24 hours. This listing is reviewed with the participant for 
completeness and correctness (second pass). The interviewer then collects detailed information 
about each reported food and beverage, including the amount consumed and method of 
preparation (third pass). In the optional fourth pass, the interviewer then probes for commonly 
forgotten foods. Finally, the detailed information is reviewed for completeness and correctness 
(fifth pass). 
Dietary supplement use will be assessed in conjunction with collection of 24-hour dietary recalls 
using the Dietary Supplement Assessment Module included in NDSR (22). Use of all types of 
dietary supplements and non-prescription antacids are queried in the module.  
The NCC Food and Nutrient Database serves as the source of food composition information in 
NDSR (23). This database includes over 18,000 foods including 7,000 brand name products. 
Ingredient choices and preparation methods provide more than 160,000 food variants. Values for 
163 nutrient, nutrient ratios and other food components are generated from the database. The 
USDA Nutrient Data Laboratory is the primary source of nutrient values and nutrient 
composition. These values are supplemented by food manufacturers' information and data 
available in the scientific literature (24). Standardized, published imputation procedures are 
applied to minimize missing values (25). 
 
6.4.2 International Physical Activity Questionnaire 
The physical activity will be assessed using the “International Physical Activity Questionnaire” 
(October 2002) in the “long last 7 days self-administered format” for “use with young and 
middle-aged adults (15-69 years)” (Source: www.ipaq.ki.se). This questionnaire comprises five 
activity domains asked independently and has been frequently validated internationally to obtain 
comparable data on health–related physical activity. The scoring protocol for the IPAQ long 
form (updated Nov 2005) is available at www.ipaq.ki.se/IPAQ.asp?mnu_sel=EEF&pg_sel=IIA. 
The questionnaire is provided in the appendix. 

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6.4.3 Activity Diary  
a) Subjects will be asked to keep an activity diary during study enrollment to record major 
changes in the daily activity patterns, e.g. starting to train for a marathon, or a change in jobs 
which alters the ratio of active/non-active time periods. This data will be used to look for internal 
consistency with data generated from the actigraphy.   
b) Subjects will be asked to fill out an activity diary during each of the 48 hour ABPM session. A 
template of the diary form from Spacelab Healthcare is provided in the appendix. 
 
6.4.4 Chronotype Questionnaire 
The Munich ChronoType Questionnaire will be administered to determine the study participants’ 
chronotype, i.e. their circadian phase preference for mornings or evenings (34) (see 
Attachments).   
 
This questionnaire divides the population, based on 50,000 participants so far, into seven 
chronotype groups. These are:  
• extreme early types; 
• moderate early types; 
• slight early types; 
• normal types; 
• slight late types; 
• moderate late types; and 
• extreme late types.  
 
In the online version available at https://www.bioinfo.mpg.de/mctq/core_work_life/core/ 
introduction.jsp?language=eng, the “chronotype is calculated from the sleep times on both work 
and free days and is given as the time of mid-sleep (half way between onset and end) on days 
when the subject would not be restricted by social obligations and would not suffer from any 
accumulated sleep debt. The duration of sleep is independent of the timing of sleep (i.e., 
Chronotype). For example, a subject who goes to sleep at 11 p.m. and wakes at 7 a.m. has the 
same chronotype as one who sleeps between midnight and 6 a.m. The distribution of chronotypes 
in the population is similar to that for height: there are few extremely short or tall people, with 
the majority being of average height. In analogy, there are few extreme early and late subjects 
and many in between.” 
6.4.5 Questionnaires delivered through the Ginger.io platform 
• 
Ginger.io Demographic Questionnaire (only at download) 
• 
Ginger.io Sleep Questionnaire (daily in the morning) 
• 
Ginger.io App Satisfaction Questionnaire (only at completion) 
Copies are provided in the appendix. 
6.5 Remote Food Photography 
Dr. Martin and colleagues developed and validated the Remote Food Photography Method® 
(RFPM) (26, 27). RFPM data are collected with the SmartIntake© smartphone app, which is 
used to streamline data collection and minimize participant burden. When using the 
SmartIntake© app, participants place a reference card next to their food and capture images of 

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their food selection and plate waste. The app has barcode scanning capabilities and a Price Look-
up (PLU) number entry system to easily identify foods in the image. The app also has text and 
voice message capability, allowing participants to easily record food descriptors that are 
automatically tagged to the food image. These data and food images are wirelessly sent by the 
app to the server-based Food Photography Application©, which is used to manage the data 
collection process and analyze the food images to estimate energy and nutrient intake. To 
facilitate data quality and completeness, the SmartIntake© app includes Ecological Momentary 
Assessment (EMA) (28) methodology to remind participants to capture images of the foods and 
beverages that they consume. These reminders are text messages that are scheduled for delivery 
at the personalized meal times of the participants. The responses to EMAs are tracked in near 
real-time, which allows the research team to quickly identify when data collection problems 
occur. In such cases, a back-up method is used (e.g., a food record or food recall conducted by 
phone). 
The SmartIntake© app sends participants food images and accompanying food identifier 
data (e.g., barcodes, PLU numbers, food descriptions) to a Pennington server where the 
Pennington team analyzes the images to estimate food intake. The analysis process relies on a 
computer program that was built by H. Ray Allen, Ph.D. and team at PBRC called the Food 
Photography Application©. The program allows the operator to identify a match for each food 
from the Food and Nutrient Database for Dietary Studies 5.0 (29) and other sources, such as 
manufacturer’s information and Nutrition Fact Panels, to calculate energy and nutrient intake. 
Additionally, the operator uses the program to estimate portion size by visually comparing 
participants’ food images to images of foods with a known portion size (i.e., standard portion 
images). This process relies on existing and validated methodology (26, 27, 30, 31).The standard 
portion images are contained in a searchable “archive” that includes over 8,000 standard portion 
images. This process results in estimates of food selected and plate waste, which is used to 
calculate food intake by difference. The RFPM has been found to accurately measure the energy 
(26, 27)  and nutrient intake of adults (26).  
Key Personnel at the Pennington Biomedical Research Center are: 
Corby K. Martin, Ph.D. 
Associate Professor 
Director, Ingestive Behavior 
Laboratory, Pennington Biomedical 
Research Center 
6400 Perkins Rd., Baton Rouge, LA 
70808 
Phone: 225-763-2585 
FAX: 225-763-3022 
email: Corby.Martin@pbrc.edu 
Mandy Cowley, M.A. 
Lab Manager 
Ingestive Behavior Laboratory 
Pennington Biomedical Research 
Center 
6400 Perkins Road 
Baton Rouge, LA 70808 
Mandy.Cowley@pbrc.edu 
225-763-2832 
 
Rebecca Schulin, RD, LDN 
Research Dietitian/Interventionist 
Ingestive Behavior Laboratory 
Pennington Biomedical Research 
Center 
6400 Perkins Road 
Baton Rouge, LA 70808 
(225)-763-3058 
rebecca.schulin@pbrc.edu 
 
Installing the SmartIntake application on a subject’s Droid-based smartphone does not require 
any personal information about the phone. The application is installed from a password protected 
website. The only PHI being transferred to the Pennington Biomedical Research Center during 
this study is the email the subject uses to send the food photos. 
 
6.6 
Urine Collections for Metabolomics Analyses 
Prior to the start of timed urine collections, subjects are advised to void their bladder. For each 
collection interval, subjects are advised to void their bladder at the end of each interval into 
labeled opaque urine containers. Subjects will be advised to store urine containers under cold 

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conditions (fridge). Urine samples will be aliquoted and frozen at -80◦C immediately after drop-
off in the CTRC. An overview of corresponding hour intervals and 24-hour clock is provided in 
the appendix. 
6.7 
Blood Collections for Metabolomics Analyses 
Blood collections will be done in Na-Heparin plasma tubes as well as serum tubes. Please see the 
appendix for the blood sampling schedule and volumes of total blood drawn throughout this 
study. 
6.8 
Saliva Collections for Metabolomics Analyses 
Saliva will be collected using Sarstedt Salivette®, a standardized hygienic saliva collection 
system. Saliva is an easily obtained biofluid which can be collected by chewing on a roll-shaped 
saliva collector. The manufacturer Sarstedt indicates that an average volume of saliva collected is 
1.1±0.3 mL.   
6.9 Nasal brush to collect epithelial cell for transcriptomic analyses 
Epithelial cells will be collected from the right/left inferior turbinate with a standard cytology 
brush, Bionix Medical Technologies, Toledo, OH or other supplier/manufacturer. Alternatively, 
a flocked nasal swab or a nasal mucosal curette can be used. Brushings will be facilitated by 
using a nasal speculum. Epithelial cell brushings will be immediately placed into  RNA lysis 
buffer and snap frozen in liquid nitrogen. Storage at -80°C until use. 
6.10 Blood Collections for Transcriptomics Analyses 
Blood collections will be done in Qiagen 2.5 mL PAXGene Blood RNA Tubes. After inverting 
gently 8x-10x, PAXgene Blood RNA Tubes will be stored upright at -80°C. 
6.11 Mouths Swabs for Microbiome Analyses 
Suitable mouths swabs are for example the “DenTek Slim Brush Cleaner (Ultra Thin Soft 
Brush)”, available from Henry Schein Inc. Furthermore, sterile tubes, e.g. BD Falcon 15mL 
High-Clarity Polypropylene Conical Tube (17x120 mm style) Sterile, are necessary to store 
mouths swabs. 
The procedure to take a mouth swab for microbiome analysis is as follows: 
1. Have participant swish mouth with water to remove any residual food particles. 
2. Remove DenTek brush from package and hold participant’s cheek away from gums. 
3. Slide brush along the base of the gum line, repeat several times with each brush to get 
lots of bacteria. 
4. Swab in the same manner for the left side, right side, and for the front gums. A total of 6 
swabs (2 in each section) will be used. 
5. Place swabs in 1x 15mL conical tube directly after swabbing. Label the tube 
appropriately. 
6. Store entire 15mL conical tube in -80°C freezer as soon as possible after collecting 
sample (this will ensure that the bacteria do not get degraded over time by saliva, heat, 
etc.).  
 
The lab of Dr. Gary Wu, Penn Gastroenterology, has established this sampling method and is 
available to assist in these efforts. 

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6.12 Fecal Swabs for Microbiome Analyses 
Rectal swab samples will be obtained by inserting a sterile swab 2-3 cm into the rectum. The 
swab will be turned 360 degrees, removed, and placed into a sterile tube and frozen until 
analysis.   
The lab of Dr. Gary Wu, Penn Gastroenterology, has established this sampling method and is 
available to assist in these efforts. 
6.13 Stool Samples for Microbiome Analyses 
Stool samples will be collected by subjects either at home or in a private bathroom within the 
CTRC. Subjects will be supplied with a collection kit and verbal and written instructions for 
stool collection at the time of consent.  Stool samples will be kept frozen in a -80°C freezer until 
analysis. Stool form will be assessed by means of the Bristol Stool Chart, a 7-point scale (35) 
provided in the appendix. 
 
As an exploratory analysis, stool water will be prepared for fecal water metabolomics (36). Stool 
samples (5-8 g) will be homogenized, then ultracentrifuged at 4 °C at 50 000 rpm (171 500g) for 
2 h. The supernatant will be separated and 2 μL of NaN3 (100 mg/mL) as an antimicrobial agent 
per gram of fecal water will be added. The fecal water samples will be stored at -80 °C as 1 mL 
aliquots.  
6.14 Water Intake 
To facilitate timed urine collections, a constant oral water intake of ≥237 ml/hour (1 cup/hour) 
during waking hours, and ad libitum water intake during sleeping hours is advised during the 
hours of scheduled urine collections. 
6.15 Vital Signs 
Blood pressure (CTRC sphygmomanometer), heart rate and temperature will be assessed as vital 
signs. 
6.16 Social Sensing Technology 
Ginger.io describes its platform as follows:  
 
The Ginger.io Platform consists of two major components: 1) the mobile application and 2) a 
web dashboard.  
 
The mobile application has two elements:  
Passive data collection:  Behavior data is gathered unobtrusively through a background 
process on the mobile device. The background process is launched automatically by 
the application once the user logs in. After the initial logon, the process continues to 
be automatically launched whenever it is not already running (on phone restart or 
other events that terminate the process).  
Active data collection: Surveys and other self-­‐report data are gathered through user 
input. This is achieved in two ways: (i) the user receives a notification that a survey is 
available and upon clicking the notification, they are transferred to the survey page, 

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(ii) the user can manually launch the application and they are shown all the surveys 
available at that time.  
 
The web dashboard is available at https://data.ginger.io and provides additional functionality 
for researchers and study administrators to manage the participants and the data collection 
process. Researchers can create studies directly on the dashboard and invite participants. 
Researchers can also monitor the data collection process through the dashboard and take 
adequate measures to reach out to customers who are not submitting surveys or whose phones 
are problematic. Further, researchers also have access to basic analytics through this 
dashboard.  
 
Currently, the Ginger.io platform allows the collection of communication data as well as 
mobility data from smartphones using the Android operating system, while the Apple iPhone 
operating system only allows the collection of mobility data. Therefore, we will only include 
subjects at this point who own and use a smartphone with the Android operating system. 
 
6.16.1 Data Collection (through Mobile Phone) and Transmission  
Upon invitation from the researcher or study administrator, users install the application and 
log in with a password provided to them. The data collection process begins soon after as 
detailed above. Passive data is gathered through a background process on the mobile phone 
and users actively submit surveys when notified through the application.  
 
   
The data is stored securely on the mobile device temporarily. At regular intervals, the 
application checks for an available connection to the WWW. If such a connection is 
available, the data is transmitted over a secure connection to the server and deleted from the 
device. If a connection is not available or if a transmission is not successful, the data 
continues to be stored on the device until it is transmitted successfully.  
 
The data collected through the device includes data such as call and sms logs (including 
call/sms time, call duration, sms length, and phone number), location and device usage. 
Private information such as actual content of voice calls or sms messages or emails is never 
read, recorded or transmitted.  
 
6.16.2 Data Storage, Encryption and Server Security  
The data described above is encrypted and transmitted to the server over a secure 128-­‐bit 
SSL 3.0 connection using the HTTPS protocol. Extra care is taken to ensure that the request 
cannot be spoofed or imitated by an attacker through the use of unique keys that are 
generated dynamically for every API request through a unique identifier and client secret that 
is embedded inside the application and cannot be accessed by any user or application.   
 
Ginger.io linux-­‐based servers are protected using a firewall and access control lists (ACLs), 
and access is restricted to Ginger.io employees and contractors. Superuser activity and 
researcher activity on the server is logged for security and auditing. The servers are regularly 
updated and patched with latest security updates to ensure that there are no known threats.   
  

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These servers host the database where the data is stored. Linux-­‐based servers and access to 
the servers is restricted to a few users responsible for maintaining and testing the database. For 
additional security, all the data that has personally identifiable information about the 
participant  (such as e-mail) is stored in a separate database from the one that has the data 
collected from the users and data related to the studies. The passively collected data from the 
phones as well as the actively-reported survey information is stored in the second database. 
Phone numbers and other such private information stored in this database are anonymized by 
hashing over the identifiers so that there is no threat to privacy because the data is not human-
readable anymore.  
 
6.16.3 Data Access (through Web Dashboard)  
Researchers and study staff have access to the web dashboard through an account on the site. 
Information pertaining to a study is only available to researchers and study staff associated 
with that study. Participants or researchers not involved in the study cannot access the data 
through the dashboard. Data accessed through the dashboard is also transmitted through 128-­‐
bit SSL 3.0 connection using the HTTPS protocol. HTTP access is disabled.  
 
Researchers or study staff can invite participants through the web dashboard. They are 
provided an option to use the study participants’ name or a coded identifier as is suitable for 
their study protocol. The coded identifier (or name) is used to refer to the participant on the 
dashboard pages and in communication with the participants.  
 
Data available on the dashboard includes aggregated or processed data about the participants 
related to the amount of data being collected (number of location samples, number of phone 
calls), time-­‐related information such as when surveys were taken, and processed data such as 
GBI features (from passive data) or survey scores (for surveys that have scoring associated 
with them). Researchers are also notified when passive data is not being collected from a 
participant or when participant is not answering surveys.  
 
6.16.4 HIPAA Compliance  
Ginger.io provides clients with a platform that is HIPAA-compliant from a technology 
standpoint as detailed in this document. It is the responsibility of the client user to remain 
HIPAA-complaint when using the Ginger.io technology within their medical practices.  
 
Ginger.io technology, security and privacy policies comply with HIPAA standards -­‐ such as 
encryption (SSL), system-­‐user identifiers (login, passwords), high-­‐end server security, 
frequent backups, strong privacy policies, and strong internal business and employee policies.  
All patient personal and health information that may be included in the Ginger.io database will 
be treated in compliance with all applicable laws and regulations. Additional security and 
privacy safeguards can be enabled upon request of the client.   
   
6.16.5 Backups  
Rotating backups are implemented weekly, monthly and daily through full server snapshots. 
Such precautionary measures make Ginger.io more resistant to hardware/software failures as 
well as human errors by enabling us to revert to a previous state in case of any issues and 
ensuring that Ginger.io does not lose any important data.  

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6.16.6 Ginger.io Privacy Philosophy  
The goal at Ginger.io is to provide a platform for patients, health care providers, and 
researchers to collect and analyze data to better understand patients’ behavior in order to 
improve their health.  Ginger.io takes their users’ privacy very seriously. Ginger.io’s 
philosophy rests on a few key principles of data ownership:  
1. 
Users own their data.  They opt-­‐in to the system, have control over the use of any 
data that is generated, and can request to have their data removed from the system.   
2. 
If data is shared, it is done in an aggregated and anonymous fashion.  Ginger.io is 
working with leading enterprise partners and academic researchers to explore ways 
of leveraging aggregate anonymous data to improve patient health.  Ginger.io 
respects the privacy and anonymity of their users and never shares specific individual 
data unless explicitly asked by their users to do so or otherwise required by law.   
3. 
Users should get value in exchange for sharing their data.   
 
Ginger.io has seen a great willingness amongst users to share their data to collectively 
advance the state of health care for themselves and for others.  Ginger.io is committed to 
continue working closely with the health and data communities to promote these innovations.   
6.16.7 Set-up and removal of the Ginger.io smartphone application 
Supervision will be provided to install and remove the Ginger.io smartphone application by the 
volunteer. Its use will be explained using a demonstration device. 
6.16.8 Potential Risks and Discomforts  
The primary risk to participants is loss of privacy. The following measures have been put in 
place to mitigate such risk:  
• The mobile data is exclusively linked to coded identifiers for the participants during 
the collection and transmission process.  
• All server transactions are transferred over a public-private key encrypted 
channel, based on the HTTPS/TLS web protocol.  
• Content of phone calls and SMS messages is never captured. Raw audio data is 
never captured.  
• Behavior data is only stored on the device until the data is uploaded to the secure 
server. In the event of a loss or misplaced phone, only data that was never 
uploaded is available on the phone.  
• Coded data stored on the secure server is only accessible to trained researchers, and 
secured with a firewall and other security measures.  
• Participants have the right to withdraw from the study at any time by uninstalling the 
application and informing the researchers. Participants can also request Ginger.io to 
have their personal data permanently deleted from our databases. However, this task 
may take 2-3 months to ensure that all traces of their behavior data are removed from 
backups. Further, it will not be possible to identify user data from aggregated 
population and study-level statistics.  
 

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6.17 Actigraphy 
Actigraphy will noninvasively assess and log the sleep, wake and activity patterns for each 
participant. In detail, data capture entails 24 hour sleep/wake measurements including total sleep 
time (TST), sleep latency, wake after sleep onset (WASO), sleep efficiency, energy expenditure, 
metabolic rates, steps taken, physical activity intensity, heart rate R-R intervals, subject position, 
and ambient light levels.  
This device will be applied as a wrist watch which facilitates incorporation into the clinical study 
setting. Actigraphy devices will be sources from e.g. ActiGraph, Pensacola, FL, 
http://www.actigraphcorp.com/company/ or similar suppliers. 
Battery life on the actigraphy devices is indicated as 22-25 days. Therefore, batteries will be 
periodically exchanged by new ones during brief CTRC visits.  
 
6.18 Ambulatory Blood Pressure Monitoring (ABPM) 
Ambulatory blood pressure monitors (ABPM) manufactured by Spacelab Healthcare are readily 
available to the investigators to assess ABP in this study protocol. The 90207 ABP monitors are 
compact and lightweight to optimize subject comfort and a choice of 5 cuff sizes further aids 
comfort while also maximizing accuracy (retrieved from the website of the manufacturer at 
http://www.spacelabshealthcare.com/en/, accessed August 28, 2012).  
 
The manufacturer indicates that the 92506 ABP Report Management System software, also 
readily available to the investigators, supports compliance with FDA and HIPAA requirements 
for integrity, availability, security, and confidentiality of protected health information (retrieved 
from the website of the manufacturer at http://www.spacelabshealthcare.com/en/, accessed 
August 28, 2012). 
 
ABPM will be guided by the AHA Scientific Statement, Council on High Blood Pressure (37). 
Recommendations relevant to the present study are: 
• Select ABP cuff size according to Table 1, 
• Select the non-dominant upper arm for ABPM measurements, 
• Instruct the patient to hold the arm still by their side while the device is taking a reading. 
 
Table 1 Cuff Sizes for ABPM 
Cuff Size* 
Ar
m 
cir
cu
mf
ere
nce 
[c
m] 
Ar
m 
cir
cu
mf
ere
nce 
[in
che
s] 
Small Adult  
17-26 
 
7-10 
 
Adult 
24-32 
 
9-13 
 

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Large Adult  
32-42 
 
13-17 
 
Extra Large Adult  
38-50 
 
15-20 
 
* The bladder of the cuff should encircle at least 80% of the arm circumference (37). 
 
The monitors for the 48-hr ambulatory blood pressure measurements will be preset to assess BP 
every 15 minutes in the daytime (0600h to 2200h) and every 30 minutes during the nighttime 
(2200h-0600h). As ABPM will be assessed over an extended period of time, 48 hours, the 
daytime intervals may be set to assess BP every 20 minutes to decrease the burden on the 
subjects and increase compliance. Preset ranges for acceptable BP measurements are 60–250 
mmHg systolic, 30-200 mmHg diastolic, and 40-230 mmHg for mean arterial values. ABP 
readings should cover ≥ 80% of the expected readings with interruptions of less than 1 hour. 
Awake and asleep times will be determined by patient diaries. This protocol is well established 
(38, 39). 
 
6.19 Metabolomics 
A dual analytical approach combining NMR and LC-MS analysis will be conducted to provide 
both quantitative and sensitive exploratory metabolomics  analysis as previously described (40). 
Samples for NMR will be ultrafiltered to remove protein components while samples for mass 
spectrometry will be separated into organic and aqueous components. 
Ultrafiltration of samples:  Ultrafiltration will be carried out as previous reported. Briefly, a 3 
kDa MW 500 μL maximum volume cutoff filter (Pall Life Sciences) will be used to separate 
macromolecular components from the metabolites of interest.  The filters will be rinsed with 
4x600 μL of distilled water to remove preservative components and centrifuged for 4x8 min (all 
centrifugation at 4oC at 10,000 rpm). 300 μL of sample will be filtered for 60 min followed by a 
final wash with 100 μL of D2O for an additional 45 minutes.  The filtrate will be dried using a 
vacuum centrifuge and the final solution contained the metabolites of interest.  
Organic extraction: 200 μL of cold methanol/chloroform (2:1; v/v) will be added to 50 μL of 
each sample, or the retentate of ultrafiltration to characterize residual lipids and/or metabolites.  
100 μL of each layer of 1:1 chloroform/water will be added and the samples will be centrifuged 
for 7 minutes at 13,300 rpm.  The upper fraction (aqueous), lower fraction (organic) will be 
separated prior to analysis. 
NMR and MS Analysis: NMR analysis of organic extracts and ultrafiltered samples will be 
conducted using a Bruker AVANCE III 700 MHz NMR equipped with a TXI triple resonance 
cryoprobe. Metabolites from NMR samples will be quantified using the ‘Targeted Profiling’ 
methodology (41). Mass spectral analysis will be conducted using a Waters UPLC-ESI-qTOF 
MS for profiling and LC-ESI-MS/MS for metabolite identification. LC-MS data will be analyzed 
by a combination of XCMS (42), public databases (43-45) and/or vender specific software and 
databases such as the Waters MarkerLynx package (Waters Corp). 
This analytical approach will adapted to analyze fecal water samples. 
6.20 Transcriptomics 
RNA will be extracted from blood using the Qiagen PAXgene blood RNA kit (Qiagen, Valencia, 
CA). RNA-seq will be performed as paired end RNA sequencing using, adapters from Illumina's 
Genomic DNA Sample Prep Kit. In previous experiments, we determined that 80 million reads 

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approach the maximum coverage depth, while >20 million read pairs, is sensitive to over 85% of 
the limiting value. We have privileged access to the Penn Genomics Frontiers Institute’s (PGFI) 
two HiSeq2000 instruments which currently generate >100 million reads per lane but will be 
upgraded to generate in excess of 300 million reads per lane in the near future. Thus, sample 
multiplexing using DNA barcoding has become feasible and will reduce the costs of this rapidly 
developing methodology. Read alignment is deceptively complicated for RNA-seq experiments 
of this size and the standard methods have required improvement for our purposes. Resolving the 
location of reads which do not span exon/exon junctions, or which span known junctions, is 
relatively straightforward as long as the genes being sequenced do not have significant 
polymorphisms with respect to the reference sequence. The introduction of polymorphisms, 
novel splice junctions, and aberrant splicing, all present considerable challenges but are common 
factors frequently encountered in data sets. The ITMAT bioinformatics group has developed a 
novel analysis pipeline that starts by processing the reads which are easy to map by using Bowtie 
(46) to align against the genome and against the transcriptome. A module is then employed 
which leverages the information from the genome and transcriptome mappings and adds 
considerable accuracy. The remaining reads are mapped with BLAT and processed with a 
complex set of filters designed to isolate the correct mapping. 
The analyses will be performed on the PGFI compute cluster, which is equipped to handle these 
data volumes. Response networks for dietary effects will be constructed using Bayesian methods 
to estimate the likelihood that detected exons/genes are to participate in the response to our 
dietary interventions. The dietary intervention response networks will be used to filter the human 
subject data so that only the most variable components of this network will be interpreted as 
candidate nodes for introducing variation in the clinical response to dietary perturbations. The 
importance of such nodes can then be followed-up in validation experiments. 
 
6.21 Genetic Analyses 
Blood samples will be stored to run future exploratory genetic analysis. These will be performed 
at the High Throughput Sequencing Facility of the Penn Genomics Frontiers Institute (PGFI) 
using the Illumina HiSeq 2000 platform. Both whole exome and whole genome sequencing will 
be performed. This will allow high quality variant calling of approximately 3 million SNPs and 
insertions and deletions (Indels). It will also allow identifying Copy Number Variations (CNV) 
and other structural rearrangements. The human samples collected for this analysis will be de-
identified and will not contain any Protected Health Information (PHI) prior to in-house sample 
distribution or shipment to external collaborators.  
 
6.22 Microbiome Analyses 
DNA from stool samples, mouth and fecal swabs stored at -80ºC will be extracted from each 
sample; PCR amplified using 16S primers, and subjected to 454/Roche pyrosequencing.  At least 
1000 sequence reads will be used to characterize each community.  The 16S sequence reads are 
then aligned using the NAST and GreenGenes servers and inserted into a well characterized 
phylogenetic trees of 16S sequences, allowing phylogenetic placement of each sequence read. As 
a first step in analyzing the global effects of each treament, we will compare microbial 
communities using UniFrac, which quantifies the similarities among microbial communities 
based on phylogenetic distances.  To compare two communities, sequences from both 
communities are placed on a common phylogenetic tree generated using ARB.  The fraction of 
the branch length on the tree unique to each community is then measured.  This provides a 
objective measure of community similarity based on the amount of shared evolutionary 

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history.  To compare multiple communities, distances between all pairs of communities are 
computed to generate a distance matrix and Principal Coordinate Analysis is used to plot 
communities in a scatter plot along orthogonal axes of maximal variance.  Such scatter plots can 
be generated taking into account the abundance as well as the presence of each taxa (weighted 
UniFrac), or using only presence/absence information (unweighted UniFrac).  The two methods 
thus address different questions--weighted analysis allows differences in proportional 
representation of community members to be assessed, while unweighted analysis discloses 
changes in community composition.  Measures of alpha diversity such as the Chao1 and 
Shannon Indices will also be used to characterize communities. 
 
6.23 Proteomics Analyses 
Circadian protein synthesis contributes to blood pressure control (47). Therefore, plasma samples 
will 
be 
submitted 
to 
a 
proteomics 
platform 
for 
analysis, 
e.g. 
SomaLogic 
(http://www.somalogic.com/Technology.aspx) 
 
6.24 Additional Analyses 
Urine electrolytes will be determined since some evidence suggests that the circadian clock 
modulates renal sodium handling (48). 
Also, cortisol, renin activity, aldosterone, creatinine clearance, GFR, and BUN will be measured.  
 
6.25 Distribution and shipment of human specimens 
 
This research project relies heavily on collaborative efforts. The human specimens collected for 
this study will be de-identified and will not contain any Protected Health Information (PHI) prior 
to in-house sample distribution or shipment to external collaborators. 
 
6.26 Clinical Study Visits 
Please see flow-chart for the study schedule as well as the blood draw schedule in the appendix 
of this protocol. The appendix also provides a comparison between hour intervals of urine 
collection and corresponding 24-hour clock time.  
6.26.1 Screening Visit 
The subject will be admitted to the outpatient unit of the Clinical and Translational Research 
Center (CTRC) at the Hospital of the University of Pennsylvania at 9 am ± 2 hours. The 
following procedures will be performed: 
1. Explain study rationale and study procedures, address questions, document in writing and 
obtain written informed consent from participant. 
2. Discuss study inclusion and exclusion criteria. 
3. Assign a subject number. 
4. Record vital signs (blood pressure, heart rate, temperature). 
5. Select correct cuff size for ABPM measurements and obtain blood pressure every 10 
minutes over one hour to assess tolerability during screening visit (≥ 6 BP 
measurements); point out to subject that blood pressure will be assessed in intervals of 20 
minutes during waking hours and in intervals of 30 minutes during sleeping hours. 
6. Record demographics. 
7. Record medical history (including medications) using the health questionnaire in the 
appendix. 

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8. CTRC Nurse Practitioner: Perform full physical examination including weight, height, 
and vital signs; for women, record the following menstrual cycle parameters: overall 
cycle length, start and end of menstrual flow, menstrual intensity, and other associated 
symptoms; 
9. Collect venous blood and urine samples for hematology (white blood cell count, red 
blood cell count, hemoglobin, hematocrit, MCV, MCH, MCHC, RCDW, and platelet 
count), serum chemistry (sodium, potassium, chloride, urea nitrogen, creatinine, fasting  
glucose, albumin, alkaline phosphatase, fasting cholesterol, HDL cholesterol and LDL 
cholesterol, triglycerides, ALT, AST, LDH, total bilirubin, GGT, uric acid, and 
phosphate), urinalysis, drug, cotinine [for nicotine] screening, urinary electrolytes, and 
self-reporting upon screen for HIV and hepatitis B/C. 
10. Collect venous blood sample for genomic analyses (provided that the subject has agreed 
and signed the informed consent form appropriately). 
11. Perform screening tests to detect drug use and smoking. 
12. Perform urine pregnancy test for women of childbearing potential. 
13. Hand out questionnaires (food frequency; physical activity), give instructions and retain 
for study binder. 
14. Explain how to take pictures of everything consumed including food, beverages and all 
snacks for the 24 hours prior to Visit V1. 
15. Schedule the next visit within 1-4 weeks from the screening visit. Once confirmed 
schedule all remaining study visits. 
6.26.2 Ginger.io Set-up Visit (Visit V1)  
1. Record vital signs. 
2. Help to set-up of Ginger.io application on subjects’ smartphone. 
3. Record AEs/SAEs. 
4. Set up dietary assessments including SmartIntake App to record everything consumed 
including food, beverages and all snacks. 
5. Schedule a test-run for the SmartIntake App. 
6. Administer Munich ChronoType Questionnaire. 
7. Set up activity diary. 
8. Re-confirm dates and times of the following study visits. 
6.26.3 Brief Visits to exchange actigraphy device (Visit V2, V3 and V12) 
1. Record vital signs. 
2. Record AEs/SAEs. 
3. Download actigraphy data. 
4. Provide fully charged actigraphy device. 
6.26.4 Preparatory Visits (Visit V4 and V8) 
1. Record vital signs. 
2. Explain again the procedures for the ABPM sessions and sequential urine collections in 
the upcoming visits. 
3. Explain again the SmartIntake App for taking pictures of everything consumed including 
food, beverages and all snacks. Explain the importance to include a standard measure 

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such as a coin or a plastic card in the size of a typical credit card with each picture. 
Confirm that timestamp and GPS tag are provided for each picture.  
4. Hand out urine collection container for interval (06:00-09:00, Day 1) hours prior to start 
of ABP recordings. 
5. Record AEs/SAEs. 
6. Re-confirm dates and times of the following study visits. 
6.26.5 Assessment Visits – Day 1 (Visit V5 and V9) 
This visit consists of two parts, a morning and evening visit to the CTRC, exactly 12 hours apart. 
1. Record vital signs (morning and evening). 
2. Download actigraphy data (only morning). 
3. Equip actigraphy device with new batteries (only morning). 
4. Only Visit V5: Have subjects’ void their bladder into urine collection container for hour 
interval (06:00-09:00, Day 1). 
5. Only Visit V9: Have subjects’ void their bladder into urine collection container for hour 
interval (06:00-09:00, Day 3). 
6. Apply ABPM instrumentation (target time: 9 am) to start the 48 hour measurement cycle; 
instruct subject how to handle ABPM equipment; hand out instruction sheet.  
7. Only Visit V5: Start urine collection for hour interval (09:00-12:00, Day 1). 
8. Only Visit V9: Start urine collection for hour interval (09:00-12:00, Day 3). 
9. Only Visit V5: Discharge subject with urine collection container and information how to 
obtain sequential urine collection for hour intervals (12:00-15:00, Day 1); (15:00-18:00, 
Day 1); (18:00-21:00, Day 1); (21:00-24:00, Day 1); (24:00-6:00, Day 1); and (06:00-
09:00, Day 1). 
10. Only Visit V9: Discharge subject with urine collection container and information how to 
obtain sequential urine collection for hour intervals (12:00-15:00, Day 3); (15:00-18:00, 
Day 3); (18:00-21:00, Day 3); (21:00-24:00, Day 3); (24:00-6:00, Day 3); and (06:00-
09:00, Day 3). 
11. Take the first blood and saliva sample (morning, target time: 9-9:30 am) and a second 
blood and saliva sample exactly 12 hours later (evening, target time: 9-9:30 pm) for 
metabolomics and transcriptomics analyses. 
12. Collect mouth and fecal swabs during morning and evening visits. 
13. Collect nasal brushings during morning and evening visits. 
14. Hand out stool collection container to collect each single bowel movement during Day 1. 
15. Collect urine containers of past collection intervals.  
16. Collect the stool containers of bowel movements since last visit. 
17. Perform urine pregnancy test for women of childbearing potential. 
18. Record AEs/SAEs (morning and evening). 
19. Re-confirm dates and times of the following study visits. 
6.26.6 Assessment Visits – Day 2 (Visit V6 and V10) 
This visit consists of two parts, a morning and evening visit to the CTRC, exactly 12 hours apart. 
1. Record vital signs (morning and evening). 
2. Collect the urine containers with sequential urine collection since the past study visit. 
3. Only Visit V6: Have subjects’ void their bladder into urine collection container for hour 
interval (06:00-09:00, Day 2). 

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4. Only Visit V10: Have subjects’ void their bladder into urine collection container for hour 
interval (06:00-09:00, Day 4). 
5. Control ABPM instrumentation (target time: 9 am) to continue the 48 hour measurement 
cycle.  
6. Only Visit V6: Start urine collection for hour interval (09:00-12:00, Day 2). 
7. Only Visit V10: Start urine collection for hour interval (09:00-12:00, Day 4). 
8. Only Visit V6: Discharge subject with urine collection container and information how to 
obtain sequential urine collection for hour intervals (12:00-15:00, Day 2); (15:00-18:00, 
Day 2); (18:00-21:00, Day 2); (21:00-6:00, Day 2); and (06:00-09:00, Day 2). 
9. Only Visit V10: Discharge subject with urine collection container and information how to 
obtain sequential urine collection for hour intervals (12:00-15:00, Day 4); (15:00-18:00, 
Day 4); (18:00-21:00, Day 4); (21:00-6:00, Day 4); and (06:00-09:00, Day 4). 
10. Take the first blood and saliva sample (morning, target time: 9-9:30 am; i.e. 12 hours 
after the last blood/saliva sample) and a second blood and saliva sample exactly 12 hours 
later (evening, target time: 9-9:30 pm) for metabolomics and transcriptomics analyses. 
11. Collect mouth and fecal swabs during morning and evening visits. 
12. Collect nasal brushings during morning and evening visits. 
13. Hand out stool collection container to collect each single bowel movement during Day 2. 
14. Collect urine containers of past collection intervals.  
15. Collect the stool containers of bowel movements since last visit. 
16. Record AEs/SAEs (morning and evening). 
17. Re-confirm dates and times of the following study visits. 
18. Schedule face-to-face interview with bionutritionist. 
6.26.7 Assessment Visits – Day 3 (Visit V7 and V11) 
1. Record vital signs. 
2. Collect the urine containers with sequential urine collection since the past study visit. 
3. Collect the stool containers of bowel movements since last visit. 
4. Take a blood and saliva sample (morning, target time: 9-9:30 am; i.e. 12 hours after the 
last blood/saliva sample) for metabolomics analyses. 
5. Collect mouth and fecal swabs. 
6. Collect nasal brushings. 
7. Collect ABPM instrumentation (target time: 9 am) to finalize the 48 hour measurement 
cycle.  
8. Have subjects list all activities and comments with approximate times over the past 48 
hours into the subject diary recall form. 
9. Record AEs/SAEs. 
10. Re-confirm date and time of the exit visit. 
6.26.8 Exit Visit (Visit V13) 
1. Record vital signs. 
2. CTRC Nurse Practitioner: Perform full physical examination including weight, height, 
and vital signs; for women, record the following menstrual cycle parameters: overall 
cycle length, start and end of menstrual flow, menstrual intensity, and other associated 
symptoms; 

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3. Collect venous blood and urine samples for hematology (white blood cell count, red 
blood cell count, hemoglobin, hematocrit, MCV, MCH, MCHC, RCDW, and platelet 
count), serum chemistry (sodium, potassium, chloride, urea nitrogen, creatinine, fasting  
glucose, albumin, alkaline phosphatase, fasting cholesterol, HDL cholesterol and LDL 
cholesterol, triglycerides, ALT, AST, LDH, total bilirubin, GGT, uric acid, and 
phosphate), and for urinalysis. 
4. Record AEs/SAEs. 
5. Remove actigraphy device. 
6. Assist in removing the Ginger.io application from the subjects’ smartphone. 
7. Assist in removing the SmartIntake application from the subjects’ smartphone. 
8. Assist in resetting the timestamp and GPS tag function to pre-study conditions. 
9. Address any unanswered question. 
 
7 
Statistical Plan 
7.1 
Sample Size Determination 
Preliminary data on the relationship between social behavior, blood pressure and metabolomics 
signatures does not exist. Therefore a formal sample size calculation was not conducted. To 
collect first pilot data, the sample size is set at n=6. Since the number of measures obtained from 
the social sensing technology as well as the metabolomics approach easily outnumbers any 
feasible number of subjects enrolled in such an exploratory study, the emphasis is on the fast 
generation of first data. This strategy is commonly used for high-dimensionality data.   
 
7.2 
Statistical Methods 
Standard summary statistics including means, standard deviations, proportions, and 95% 
confidence intervals will be produced for all measures. The focus of the data exploration will be 
on exploring the shape of the curves over time, as well as identifying peaks and troughs. 
The data generated in this study are multimodal and dispersed across time and space. Outcomes 
are i) behavioral features (call/SMS/missed interactions count [number/hour], call duration 
[minutes/ hour], SMS length [characters/hour], interaction diversity [unique individuals/hour], 
aggregate communication [minutes/hour] and mobility radius [miles/hour]);  ii) 48-hour blood 
pressure (mean arterial pressure, pulse pressure, systolic/diastolic blood pressure [mmHg], 
heart rate [beats/minute], average real-time variability (ARV) [%]); iii) metabolomics (urine 
[ng/mg creatinine] and plasma/serum metabolites [ng/mL]).  
For the Primary Study Endpoint, the diurnal behavior of each of the relevant measurements that 
are provided by the Ginger.io platform will be identified and characterized. Standard methods 
will be applied (49). We will identify individual-specific behavioral patterns and population-
wide signatures in a behavioral data set spanning three months of collecting social activity data. 
We will investigate the extent to which records of sleep patterns and/or other metrics can be used 
to normalize the multi-dimensional data across subjects. This will establish a universal time scale 
in order to make their diurnal patterns comparable and hence, enable a proper replicate analysis 
as needed for the Secondary Study Endpoint.  
For the Secondary Study Endpoint, we will identify the relationships between the social and 
biological factors that are not confounded due to their mutual circadian behavior but which 
hypothesize a causal link between them. This will be achieved by compiling comparable 

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measurements (using universal time determined in the Primary Study Endpoint) across all 
individuals at fixed universal time points. With n=6 subjects, the total observational period of 
96 hours for the biological measurements will enable robust correlation analyses between all 
pairs of relevant factors for this pilot investigation. 
 
7.3 
Subject Population(s) for Analysis 
Any subject randomized into the study will be included in subject population whose data will be 
subjected to analysis. 
8 
Safety and Adverse Events 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency  (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators brochure, 
etc) 
• Related or possibly related to participation in the research (i.e. possibly related means 
there is a reasonable possibility that the incident experience, or outcome may have been 
caused by the procedures involved in the research) 
• Suggests that the research places subjects or others at greater risk of harm (including 
physical, psychological, economic, or social harm). 
 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in 
severity during the course of the study. Intercurrent illnesses or injuries should be regarded as 
adverse events. Abnormal results of diagnostic procedures are considered to be adverse events if 
the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that 
is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly 
of major clinical significance.   They may jeopardize the subject, and may require intervention to 
prevent one of the other serious outcomes noted above.  For example, drug overdose or abuse, a 

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seizure that did not result in in-patient hospitalization, or intensive treatment of bronchospasm in 
an emergency department would typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-
serious adverse events.  
 
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up.  For this 
study, the study treatment follow-up is defined as 30 days following the last administration of 
study treatment.  
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an adverse 
event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the last 
scheduled visit, the investigator should instruct each subject to report any subsequent event(s) 
that the subject, or the subject’s personal physician, believes might reasonably be related to 
participation in this study.  The investigator should notify the study sponsor of any death or 
adverse event occurring at any time after a subject has discontinued or terminated study 
participation that may reasonably be related to this study.  The sponsor should also be notified if 
the investigator should become aware of the development of cancer or of a congenital anomaly 
in a subsequently conceived offspring of a subject that has participated in this study.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the 
following conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic 
investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 

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Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 
this protocol.  Any condition responsible for surgery should be documented as an adverse event 
if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures 
for a preexisting condition.  Surgery should not be reported as an outcome of an adverse 
event if the purpose of the surgery was elective or diagnostic and the outcome was 
uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement for 
the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the study, 
unless it is a worsening or increase in frequency of hospital admissions as judged by the 
clinical investigator. 
 
8.2 
Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events 
should be recorded immediately in the source document, and also in the appropriate adverse 
event module of the case report form (CRF).  All clearly related signs, symptoms, and abnormal 
diagnostic procedures results should recorded in the source document, though should be grouped 
under one diagnosis. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of 
each event should be followed until resolution, stabilization, or until it has been determined that 
the study treatment or participation is not the cause.  Serious adverse events that are still ongoing 
at the end of the study period must be followed up to determine the final outcome.  Any serious 
adverse event that occurs after the study period and is considered to be possibly related to the 
study treatment or study participation should be recorded and reported immediately. 
 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
Investigators and the protocol sponsor must conform to the adverse event reporting timelines, 
formats and requirements of the various entities to which they are responsible, but at a minimum 
those events that must be reported are those that are: 
• related to study participation, 
• unexpected, and  
• serious or involve risks to subjects or others  
(see definitions, section 8.1).   
If the report is supplied as a narrative, the minimum necessary information to be provided at the 
time of the initial report includes: 

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• Study identifier 
• Study Center 
• Subject number 
• A description of the event 
• Date of onset 
• Current status 
• Whether study treatment was discontinued 
• The reason why the event is classified as 
serious 
• Investigator assessment of the association 
between the event and study treatment 
 
8.3.1 Investigator reporting: notifying the Penn IRB 
This section describes the requirements for safety reporting by investigators who are Penn 
faculty, affiliated with a Penn research site, or otherwise responsible for safety reporting to the 
Penn IRB. The University of Pennsylvania IRB (Penn IRB) requires expedited reporting of those 
events related to study participation that are unforeseen and indicate that participants or others 
are at increased risk of harm.  The Penn IRB will not acknowledge safety reports or bulk adverse 
event submissions that do not meet the criteria outlined below.  The Penn IRB requires 
researchers to submit reports of the following problems within 10 working days from the time 
the investigator becomes aware of the event: 
• Any adverse event (regardless of whether the event is serious or non-serious, on-site or 
off-site) that occurs any time during or after the research study, which in the opinion of 
the principal investigator is: 
Unexpected (An event is “unexpected” when its specificity and severity are not accurately 
reflected in the protocol-related documents, such as the IRB-approved research protocol, 
any applicable investigator brochure, and the current IRB-approved informed consent 
document and other relevant sources of information, such as product labeling and package 
inserts.) 
AND 
Related to the research procedures (An event is “related to the research procedures” if in 
the opinion of the principal investigator or sponsor, the event was more likely than not to 
be caused by the research procedures.) 
 
Reporting Process 
Unanticipated problems posing risks to subjects or others as noted above will be reported to the 
Penn IRB using the form: “Unanticipated Problems Posing Risks to Subjects or Others Including 
Reportable Adverse Events” or as a written report of the event (including a description of the 
event with information regarding its fulfillment of the above criteria, follow-up/resolution and 
need for revision to consent form and/or other study documentation). 
 
Copies of each report and documentation of IRB notification and receipt will be kept in the 
Clinical Investigator’s study file. 
 
8.4 
Reporting of any breaches of confidentiality to the Ginger.io system 
Details on how Ginger.io will be reporting any breaches of confidentiality to their system back to 
the study site are as follows: 
1) The designated person at Ginger.io reports any breaches of confidentiality to their system 
back to the study site within 5 business days after becoming first aware of the breach; 
2) The designated person at Ginger.io will characterize the extent of breach by providing in 
writing i) what kind of data has been compromised, ii) who of the users/subjects has been 

Human Circadian Rhythmicity 
 
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Version: July 11, 2014 
 
compromised, iii) how long the breach existed (start and end times and dates), iv) what 
immediate measures have been taken to remedy the breach; 
3) Recipients of Ginger.io's reports on the side of the study site is i) a designated investigator of 
the study team, and ii) a designated member of the UPENN IRB to be determined; 
4) The designated investigator and the designated IRB member discuss and agree on a course of 
action within 5 business days. 
 
Names and contact information of the designated persons are: 
 
Ginger.io 
Sasank Mudunuri 
965 Mission St, Suite 730, San Francisco, CA 94103 
Telephone: 1-855-446-4374 
e-mail: sasank@ginger.io 
 
Investigator UPENN 
Carsten Skarke, MD 
Institute for Translational Medicine and Therapeutics (ITMAT), 
University of Pennsylvania School of Medicine, 
8036 Maloney Bldg., 3600 Spruce St 
Philadelphia, PA 19104 
Telephone: 215.746.8330 
e-mail: cskarke@mail.med.upenn.edu   
 
8.5 
Stopping Rules 
A subject may withdraw from the trial at any time with or without giving reasons. A subject may 
withdraw her/his subject consent at any time. The participation of a subject may, at any moment, 
be terminated by the investigator, if he/she considers that it will be in the subject’s best interest. 
Subjects may be withdrawn at the discretion of the Investigator for reasons of medical prudence. 
8.6 
Medical Monitoring 
A designated, qualified medical monitor from the Institute of Translational Medicine and 
Therapeutics will be reviewing subjects’ safety labs, SAE/AE reporting and subjects' overall 
study course to monitor for missed AEs/SAEs. The medical monitor will use the template 
provided in the appendix. 
9 
Data Handling and Record Keeping 
9.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 

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In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at 
the end of their scheduled study period. 
9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents.  Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ 
diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories, and at medico-technical departments involved 
in the clinical trial. 
9.3 
Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study.  All 
data requested on the CRF must be recorded.  All missing data must be explained.  If a space on 
the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”.  If the item is not applicable to the individual case, write “N/A”.  All entries should be 
printed legibly in black ink.  If any entry error has been made, to correct such an error, draw a 
single straight line through the incorrect entry and enter the correct data above it.  All such 
changes must be initialed and dated.  DO NOT ERASE OR WHITE OUT ERRORS.  For 
clarification of illegible or uncertain entries, print the clarification above the item, then initial and 
date it. 
9.4 
Data Management 
The UPenn-based data management software REDCap (http://project-redcap.org/) will be 
deployed to collect and store study data. REDCap (Research Electronic Data Capture) is a secure 
web application for building and managing online surveys and databases. Using REDCap's 
stream-lined process for rapidly developing projects, one may create and design projects using 1) 
the online method from your web browser using the Online Designer; and/or 2) the offline 
method by constructing a 'data dictionary' template file in Microsoft Excel, which can be later 
uploaded into REDCap. Both surveys and databases (or a mixture of the two) can be built using 
these methods. REDCap provides audit trails for tracking data manipulation and user activity, as 
well as automated export procedures for seamless data downloads to Excel, PDF, and common 
statistical packages (SPSS, SAS, Stata, R). Also included are a built-in project calendar, a 
scheduling module, ad hoc reporting tools, and advanced features, such as branching logic, file 
uploading, and calculated fields. 
9.5 
Records Retention 
Study essential documents will be retained for 7 years after completion of research. 
9.6 
Data Handling, Record Keeping, and Confidentiality in relation to the Ginger.io 
smartphone application 
Please refer to section 6.8. 

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10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
For this investigator-initiated study, the investigators will provide continued regulatory oversight 
of study activities in order to ensure that regulatory requirements and GCP guidelines are being 
followed. Therefore, an external monitor will not be appointed. A brief check-list is being kept to 
facilitate the documentation of the investigators’ oversight of this clinical trial. All investigators 
have access to the study-related documents and study related facilities (e.g. pharmacy, diagnostic 
laboratory, etc.).  
 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the 
sponsor, government regulatory bodies, and University compliance and quality assurance groups 
of all study related documents (e.g. source documents, regulatory documents, data collection 
instruments, study data etc.). The investigator will ensure the capability for inspections of 
applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
 
11 Ethical Considerations 
This study is to be conducted in accordance with applicable US government regulations and 
international standards of Good Clinical Practice, and applicable institutional research policies 
and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent 
Institutional Review Board (IRB), in agreement with local legal prescriptions, for formal 
approval of the study conduct.  The decision of the IRB concerning the conduct of the study will 
be made in writing to the investigator and a copy of this decision will be provided to the sponsor 
before commencement of this study.  
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  See Attachment for a copy of the Subject Informed Consent Form.  This consent form 
will be submitted with the protocol for review and approval by the IRB for the study.  The 
formal consent of a subject, using the IRB-approved consent form, must be obtained before that 
subject undergoes any study procedure.  The consent form must be signed by the subject or 
legally acceptable surrogate, and the investigator-designated research professional obtaining the 
consent.  
12 Study Finances 
12.1 Funding Source 
This study is financed through departmental funds. Ginger.io will provide all services pertaining 
to the social sensing technology at no cost to the University of Pennsylvania principal 
investigators. 

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12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or 
financial gain greater than the minimum allowable by their institution, etc.) must have the 
conflict reviewed by a properly constituted Conflict of Interest Committee with a Committee-
sanctioned conflict management plan that has been reviewed and approved by the study sponsor 
prior to participation in this study. All University of Pennsylvania investigators will follow the 
applicable University conflict of interest policies. 
12.3 Subject Payments 
Subjects will receive $840. This payment will be prorated as follows: $50 for completing the 
screening visit; $300 for completion of each of the two 48-hour sessions of combined ambulatory 
blood pressure monitoring and urine, blood and saliva collection, mouth and fecal swabs, nasal 
brushings, as well as food photography; $25 for completion of each of the four brief study visits 
to the CTRC; $30 for completion of each of the three months of daily sleep surveys and 
incidental entries into the activity diary. In addition, up to $40 may be compensated for costs 
related to the increased data transfer when using the apps Ginger.io and SmartIntake. Subjects 
are asked to provide an invoice showing the additional costs.    
13 Master License Agreement 
With regard to the Ginger.io smartphone app, this research will be conducted with a master 
license agreement in place between The University of Pennsylvania and Ginger.io. 
With regard to the SmartIntake app, this research will be conducted with a master license 
agreement in place between The University of Pennsylvania and the Pennington Biomedical 
Research Center. 
 
14 Security and Privacy Information Impact Assessment 
For the Ginger.io platform, a security and privacy impact assessment (SPIA) has been conducted 
by the University of Pennsylvania Information Security Office. The resulting SPIA and the no-
revisions letter are provided as copies in the appendix. 
 
For the SmartIntake platform, a security and privacy impact assessment (SPIA) has been 
conducted by the University of Pennsylvania Information Security Office. The resulting SPIA 
and the no-revisions notification to the IRB occurred on June 20, 2014 executed by Mr. Michael 
Moran. 
15 Publication Plan 
Drs. Garret A. FitzGerald, Carsten Skarke and Aalim Weljie hold jointly the primary 
responsibility for publication of the results of this study.  
16 Trial Registration 
This study will be registered in ClinicalTrials.gov.  
17 References 
1. 
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Arterioscler Thromb Vasc Biol. 2007;27(8):1694-705. 

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Curtis AM, Fitzgerald GA. Central and peripheral clocks in cardiovascular and metabolic function. 
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Paschos GK, Baggs JE, Hogenesch JB, FitzGerald GA. The role of clock genes in pharmacology. 
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4. 
Shea SA, Hilton MF, Hu K, Scheer FA. Existence of an endogenous circadian blood pressure 
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Dallmann R, Viola AU, Tarokh L, Cajochen C, Brown SA. The human circadian metabolome. 
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6. 
Ang JE, Revell V, Mann A, Mantele S, Otway DT, Johnston JD, et al. Identification of Human 
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Walsh MC, Brennan L, Malthouse JP, Roche HM, Gibney MJ. Effect of acute dietary 
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Takeda I, Stretch C, Barnaby P, Bhatnager K, Rankin K, Fu H, et al. Understanding the human 
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Champagne CM, Bray GA, Kurtz AA, Monteiro JB, Tucker E, Volaufova J, et al. Energy intake 
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Landberg R, Aman P, Friberg LE, Vessby B, Adlercreutz H, Kamal-Eldin A. Dose response of 
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O'Brien DM, Kristal AR, Jeannet MA, Wilkinson MJ, Bersamin A, Luick B. Red blood cell 
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Madan A, Cebrian M, Lazer D, Pentland A. Social Sensing to Model Epidemiological Behavior 
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Madan A, Moturu S, Lazer D, Pentland A. Social Sensing: Obesity, Unhealthy Eating and 
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Feskanich D, Sielaff BH, Chong K, Buzzard IM. Computerized collection and analysis of dietary 
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Johnson RK, Driscoll P, Goran MI. Comparison of multiple-pass 24-hour recall estimates of 
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Harnack L, Stevens M, Van Heel N, Schakel S, Dwyer JT, Himes J. A computer-based approach 
for assessing dietary supplement use in conjunction with dietary recalls. J Food Compost Anal. 
2008;21(Suppliment 1):S78-S82. 
23. 
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Schakel SF, Sievert YA, Buzzard IM. Sources of data for developing and maintaining a nutrient 
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Schakel S, Buzzard I, Gebhardt S. Procedures for estimating nutrient values for food composition 
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Food Photography Method (RFPM) for estimating energy and nutrient intake in near real-time. 
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Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 
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USDA Food and Nutrient Database for Dietary Studies, 5.0, 2012. U.S. Department of 
Agriculture, Agricultural Research Service, Food Surveys Research Group, Beltsville, MD. 2012. 
30. 
Williamson DA, Allen HR, Martin PD, Alfonso A, Gerald B, Hunt A. Digital photography: a new 
method for estimating food intake in cafeteria settings. Eat Weight Disord. 2004;9(1):24-8. 
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Williamson DA, Allen HR, Martin PD, Alfonso AJ, Gerald B, Hunt A. Comparison of digital 
photography to weighed and visual estimation of portion sizes. J Am Diet Assoc. 
2003;103(9):1139-45. 
32. 
Pellegrini CA, Duncan JM, Moller AC, Buscemi J, Sularz A, DeMott A, et al. A smartphone-
supported weight loss program: design of the ENGAGED randomized controlled trial. BMC Public 
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33. 
Carter MC, Burley VJ, Nykjaer C, Cade JE. 'My Meal Mate' (MMM): validation of the diet 
measures captured on a smartphone application to facilitate weight loss. Br J Nutr. 2012:1-8. 
34. 
Roenneberg T, Wirz-Justice A, Merrow M. Life between clocks: daily temporal patterns of human 
chronotypes. J Biol Rhythms. 2003;18(1):80-90. 
35. 
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J 
Gastroenterol. 1997;32(9):920-4. 
36. 
Gao X, Pujos-Guillot E, Sebedio JL. Development of a quantitative metabolomic approach to 
study clinical human fecal water metabolome based on trimethylsilylation derivatization and 
GC/MS analysis. Anal Chem. 2010;82(15):6447-56. 
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blood pressure measurement in humans: an AHA scientific statement from the Council on High 
Blood Pressure Research Professional and Public Education Subcommittee. J Clin Hypertens 
(Greenwich). 2005;7(2):102-9. 
38. 
Pepperell JC, Ramdassingh-Dow S, Crosthwaite N, Mullins R, Jenkinson C, Stradling JR, et al. 
Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway 
pressure for obstructive sleep apnoea: a randomised parallel trial. Lancet. 2002;359(9302):204-
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39. 
Harshfield GA, Hwang C, Grim CE. Circadian variation of blood pressure in blacks: influence of 
age, gender and activity. J Hum Hypertens. 1990;4(1):43-7. 
40. 
Farshidfar F, Weljie AM, Kopciuk K, Buie WD, Maclean A, Dixon E, et al. Serum metabolomic 
profile as a means to distinguish stage of colorectal cancer. Genome Med. 2012;4(5):42. 
41. 
Weljie AM, Newton J, Mercier P, Carlson E, Slupsky CM. Targeted profiling: quantitative analysis 
of 1H NMR metabolomics data. Anal Chem. 2006;78(13):4430-42. 
42. 
Smith CA, Want EJ, O'Maille G, Abagyan R, Siuzdak G. XCMS: processing mass spectrometry 
data for metabolite profiling using nonlinear peak alignment, matching, and identification. Anal 
Chem. 2006;78(3):779-87. 
43. 
Cui Q, Lewis IA, Hegeman AD, Anderson ME, Li J, Schulte CF, et al. Metabolite identification via 
the Madison Metabolomics Consortium Database. Nat Biotechnol. 2008;26(2):162-4. 
44. 
Wishart DS, Tzur D, Knox C, Eisner R, Guo AC, Young N, et al. HMDB: the Human Metabolome 
Database. Nucleic Acids Res. 2007;35(Database issue):D521-6. 
45. 
Smith CA, O'Maille G, Want EJ, Qin C, Trauger SA, Brandon TR, et al. METLIN: a metabolite 
mass spectral database. Ther Drug Monit. 2005;27(6):747-51. 
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47. 
Stow LR, Richards J, Cheng KY, Lynch IJ, Jeffers LA, Greenlee MM, et al. The circadian protein 
period 1 contributes to blood pressure control and coordinately regulates renal sodium transport 
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48. 
Nikolaeva S, Pradervand S, Centeno G, Zavadova V, Tokonami N, Maillard M, et al. The 
circadian clock modulates renal sodium handling. J Am Soc Nephrol. 2012;23(6):1019-26. 
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Ahdesmaki M, Lahdesmaki H, Pearson R, Huttunen H, Yli-Harja O. Robust detection of periodic 
time series measured from biological systems. BMC bioinformatics. 2005;6:117. 
 
 
 

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Appendix Page 1 
 
18 Appendix 
18.1 Study Flow-Chart 
Visit No. to CTRC  
SCR 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 
V11 
V12 
V13-
Exit 
Month 
-1 
1 
1 
2 
3 
3 
3 
3 
3 
3 
3 
3 
4 
4 
Week  
 
1 
4 
7 
9 
10 
10 
10 
11 
12 
12 
12 
15 
18 
Day 
Mon-
Fri 
Wed±2 Wed±2 Wed±2 Wed±2 Tues±1 Wed±1 Thur±1 Wed±2 Tues±1 Wed±1 Thur±1 Wed±2 Mon-Fri 
Hours in CTRC 
2 
1 
0.25 
0.25 
0.5 
1.5 
1.5 
1.5 
0.5 
1.5 
1.5 
1.5 
0.25 
1 
Demographics  
X  
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent  
X  
 
 
 
 
 
 
 
 
 
 
 
 
 
In- / exclusion criteria  
X  
 
 
 
 
 
 
 
 
 
 
 
 
 
Compliance1 
X  
 
 
 
 
X 
 
 
 
X 
 
 
 
 
Medical History / Physical  
X  
 
 
 
 
 
 
 
 
 
 
 
 
X 
Routine laboratory screen  
X  
 
 
 
 
 
 
 
 
 
 
 
 
X 
Questionnaires (3-day food 
record; Physical Activity; 
chronotype) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionnaires (24-hour 
dietary recall) 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
Face-to-face interview w/ 
bionutritionist 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Taking pictures of 
everything consumed2 
 
X 
 
 
 
X 
X 
X 
 
X 
X 
X 
 
 
Actigraphy 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Actigraphy battery change 
 
 
X 
X 
 
X 
 
 
 
X 
 
 
X 
 
Set-up & removal of 
Ginger.io technology 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Monitoring User Activity
  
 
X 
X 
X 
X 
X 
X 
X
  
X
  
X  
X
  
X
  
X 
 
Sleep questionnaire3 
 
X 
X 
X 
X 
X 
X 
X
  
X
  
X  
X
  
X
  
X 
 
Ambulatory blood pressure 
monitoring4 
 
X7 
 
 
 
X 
X 
X 
 
X 
X 
X 
 
 
Sequential urine 
collections5 
 
 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 2 
 
Blood and saliva samples6 
 
X7 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 
Nasal brushings6 
 
X7 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 
Metabolomics 
 
 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 
Transcriptomics 
 
 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 
Proteomics 
 
 
 
 
 
X 
X 
X 
 
X 
X 
X 
 
 
Microbiome analyses 
(stool, mouth, rectum) 
 
 
 
 
 
X  
X  
X  
 
X  
X  
X  
 
 
Genetic analyses 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vital Signs  
X  
X  
X 
X 
X  
X  
X  
X  
X  
X  
X  
X  
X 
X  
Assessment AEs/SAEs  
 
X  
X 
X 
X  
X  
X  
X  
X  
X  
X  
X  
X 
X  
Activity Diary8 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
 
Footnotes:  
1) Urine pregnancy, urine drug and urine cotinine test.  
2) SmartIntake App on smartphone: Capturing picture of everything consumed including food, beverages and snacks starts shortly before the 48 hour period of 
ABPM  
3) Sleep questionnaire consists of the single question: “How many hours did you sleep last night?" which will be administered through the smartphone app on a 
daily basis. Alternatively, if the Ginger.io technology can provide this, the exact hours of in-bed and out-of-bed will be surveyed. Options to realize this on the 
smartphone include for example a free text entry or a dial.    
4) 9 am as target start time.  
5) Sequential 3-hour urine collection intervals during waking hours plus a 6-hour collection interval during sleeping hours, i.e. 0-3, 3-6, 6-9, 9-12, 12-15, 15-21, 
21-24, 24-27, 27-30, 30-33, 33-36, 36-39, 39-45, and 45-48. Start of urine collections coincides with start of the 48 hour period of ABPM; corresponding 24-hour 
clock urine collection intervals are 09:00-12:00; 12:00-15:00; 15:00-18:00; 18:00-21:00; 21:00-24:00; 24:00-6:00; 06:00-09:00. Subject will be familiarized with 
ABPM measurements and equipment for ≥ 2 hours during the screening visit. 
6) Blood and saliva samples in exactly 12-hour ‘anti-phase’ intervals at time points 0, 12, 24, 36, and 48 after the start of urine collections and ABPM recordings. 
7) Test-run of procedures to assess how participants tolerate ambulatory blood pressure monitoring and specimen collection via swabs and brushes. 
8) Subjects will be asked to keep an activity diary during study enrollment to record major changes in the daily activity patterns, e.g. starting to train for a 
marathon, or a change in jobs which alters the ratio of active/non-active time periods.      
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 3 
 
18.2 Blood sample Schedule 
 
  
 
 
 
Human Circadian Rhythmicity
SCR
V1    
morning
V2    
morning
V3    
morning
V3    
evening
V4    
morning
V4    
evening
V5    
morning
V6    
morning
V7    
morning
V7    
evening
V8    
morning
V8    
evening
V9    
morning
V10-Exit  
morning
Week 
1
9
10
10
10
10
10
11
12
12
12
12
12
17
Day
Mon-
Fri
Wed±
2
Wed±
2
Tues±
1
Tues±
1
Wed±
1
Wed±
1
Thur±1 Wed±
2
Tues±
1
Tues±
1
Wed±
1
Tues±
1
Thur±1 Mon-Fri
Laboratory Screens
CBC, EDTA-Plasma, 1x 4.0 mL Purple Top Tube
4
4
Chemistry, Serum, 1x 6.0 mL Gold Top Tube
6
6
Platelet Aggregation, Na-Citrate, 1 x 4.5 mL Blue Top Tube
4.5
4.5
4.5
Metabolomic & Proteomics Analyses
Metabolomics, Na-Heparin-Plasma, 2x 6.0 mL Green Top 
Tube 
12
12
12
12
12
12
12
12
12
12
Metabolomics, Serum, 2x 6.0 mL Red Top Tube 
12
12
12
12
12
12
12
12
12
12
Clinical Labs
EDTA-Plasma, 2x8.0 mL Lavender Top Tube
16
16
Serum, 1x 6.0 mL Red Top Tube 
6
6
6
6
6
6
6
6
6
6
Serum, 2x 6.0 mL Red Top Tube 
12
12
Transcriptomic/genetic Analyses
Transcriptomics, PAXgene Blood RNA Tubes, 2x 2.5 mL
5
5
5
5
5
5
5
5
5
5
Genetic analyses, Buffy Coat, EDTA, 1x 4.0 mL Purple Top 
Tube
4
Subtotals [ml] per subject
18.5
0
0
39.5
35
63
35
35
0
39.5
35
63
35
35
10
Total [ml] per subject 
Blood [mL] allocated for repeat blood draws 
only if necessary due to e.g. processing 
error
Maximum volume of blood draws [mL]
443.5
36
479.5

Human Circadian Rhythmicity 
 
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Appendix Page 0 
 
18.3 Hour intervals versus 24-hour clock 
 
 
 
 
Day #
1 or 3
1 or 3
1 or 3
1 or 3
1 or 3
1 or 3
1 or 3
Daytime vs Nighttime
Daytime
Daytime
Daytime
Daytime
Daytime
Nighttime
Daytime
24-hour clock
09:00-12:00
12:00-15:00
15:00-18:00
18:00-21:00
21:00-24:00
24:00-06:00
06:00-09:00
Hour Interval
0-3
3-6
6-9
9-12
12-15
15-21
21-24
Day #
2 or 4
2 or 4
2 or 4
2 or 4
2 or 4
2 or 4
2 or 4
Daytime vs Nighttime
Daytime
Daytime
Daytime
Daytime
Daytime
Nighttime
Daytime
24-hour clock
09:00-12:00
12:00-15:00
15:00-18:00
18:00-21:00
21:00-24:00
24:00-06:00
06:00-09:00
Hour Interval
24-27
27-30
30-33
33-36
36-39
39-45
45-48

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 1 
 
 
18.4 Health Questionnaire 
Health Questionnaire 
Personal Information: 
 
 
 
 
 
 
Name:____________________________________ 
Home phone:______________________________ 
Address:__________________________________ 
Work phone: (optional):_____________________ 
City, State, Zip:____________________________ 
Email:____________________________________ 
Occupation:_______________________________ 
Fax #: ____________________________________ 
 
Contact Person:____________________________ 
Phone:____________________________________ 
 
Physicians to Receive Letters:   
1) Primary MD :____________________________ 
Address:__________________________________ 
 
 
 
 
 
 
  
__________________________________________ 
Phone:_____________________________    
Fax #:____________________________________ 
 
2) Other MD:____________________________ Address:__________________________________ 
Specialty: ___________________________ 
  
__________________________________________ 
Phone:_____________________________    
Fax #: ____________________________________ 
 
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 2 
 
Demographics 
Gender:   M / F  In terms of ethnicity, do you consider yourself Hispanic or Latino?  Yes/No 
 
                                                                                  In terms of race, do you consider yourself? 
Date of Birth:______________  
 
1-American Indian/Alaska Native 
Yes /  No 
Age:__________ 
 
 
 
 
2-Asian  
 
 
Yes /  No 
Height:__________ 
 
 
 
 
3-Black or African American 
 
Yes /  No 
Weight:_______________  
 
 
 
4-Native Hawaiian/Pacific Islander     Yes / No 
 
 
 
 
 
 
 
4-White 
 
 
 
 Yes / No 
5-other______________________ 
 
Heart Risk Assessment: 
1. Do you currently smoke cigarettes/cigars/pipe? 
 
Yes / No 
If yes, how may per day or week? 
 
 
Number:  _________   Per: day / week (circle) 
 
If no, have you ever smoked? 
 
 
Yes / No 
 
For how many years did you/have you smoked?  ______________________ 
 
2.  Do you drink alcohol?   
 
Yes / No 
If yes, How much do you drink?  
 
a) >1 drink  per day 
 
 
b) 1 drink per day 
c) <1 drink per day but > 1 drink per week  
 
d) < 1 drink per week 
 If yes, what kind of alcohol beverages do you drink? 
Please describe: _____________________________ 
___________________________________________ 
___________________________________________ 
___________________________________________ 
___________________________________________ 
___________________________________________ 
 
3.  How often do you exercise?  
 
 
a) every day 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 3 
 
(for example walking, running, 
 
 
 
b) three times a week 
biking, swimming or gym work-out) 
 
 
c) once a week 
       
 
 
d) once a month or less 
e) not at all 
 
Past Medical History 
1.  Do you have or did you ever have High Blood Pressure?   
 
 
Yes / No / Don’t know  Year of Diagnosis:_______ 
2.  Do you have or did you ever have High Cholesterol?  
 
Yes / No / Don’t know   Year of Diagnosis:________ 
3.  Do you have diabetes?   
 
 
Yes/No/Don’t know 
Year of Diagnosis:  __________________ 
4.  Have you been diagnosed with rheumatoid or osteoarthritis?    
 
Yes / No / Don’t know   Year of Diagnosis:________ 
5.  Have you been diagnosed with hepatitis or any other liver disease?   Yes / No / Don’t know    
 
Diagnosis:_____________________________________ Year of Diagnosis: _____________ 
6.  Have you been diagnosed with HIV / AIDS or any other infectious disease?   Yes / No / Don’t know    
Diagnosis:_____________________________________ Year of Diagnosis:______________ 
7. Have you ever been diagnosed with cancer of any type (including skin cancer)? 
 
 
Yes / No / Don’t know    
 
Diagnosis:_____________________________________ Year of Diagnosis: _____________ 
8.  If Female:   Postmenopausal? 
 
 
 
 
Yes / No / Don’t know  
Year of last menstrual period:_________ 
 
 
Both ovaries surgically removed? 
 
 
 
 
Yes / No / Don’t know         
Year removed:____________ 
 
 
Are you taking hormone replacement therapy?      
 
 
 
Yes / No 
     
 
How many years?__________ 
 
 
Did you ever take hormone replacement therapy? 
 
 
 
 
Yes / No            
 
How many years?_________ 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 4 
 
 Family History: 
Do you have a family history of heart attack or stroke?   
Yes                 No 
 Don’t know 
 
 
 
 
 
 
Age at time of heart  
 
 
 
attack or stroke?             Current Age? 
 
Alive? 
Biological mother  
Yes / No / Don’t know _____________              ______________ Yes / No / Don’t know 
Biological father  
Yes / No / Don’t know ______________            ______________ Yes / No / Don’t know  
Biological brothers   1) Yes / No / Don’t know ______________  
______________ Yes / No / Don’t know 
or half-brothers         2)  Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know    
                                  3)  Yes / No / Don’t know  ______________            _____________  Yes / No / Don’t know  
  
 
        4) Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know 
Biological sisters      1)  Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know 
or half-sisters            2)  Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know   
 
 
        3) Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know  
        4)  Yes / No / Don’t know ______________             _____________  Yes / No / Don’t know 
*if  >8 siblings, list on back of this sheet  
 
Cardiovascular History 
1. Have your doctors ever diagnosed you with:   
 
heart disease  
 
 
 
 
 
 
 
Yes / No / Don’t know    
 
What?___________________________________________________________ 
 
heart attack 
 
 
 
 
 
 
 
Yes / No / Don’t know     
angioplasty or stent of a heart (coronary) artery  
 
 
Yes / No / Don’t know  
heart bypass surgery 
 
 
 
 
 
 
Yes / No / Don’t know 
stroke  
 
 
 
 
 
 
 
Yes / No / Don’t know  
ministroke or TIA 
 
 
 
 
 
 
Yes / No / Don’t know  
neck (carotid) artery blockage/narrowing/bypass surgery  
 
Yes / No / Don’t know  
 
 
blocked/narrowed arteries in your legs  
 
 
 
Yes / No / Don’t know  
bypass surgery of your leg arteries 
 
 
 
 
Yes / No / Don’t know  
angioplasty/stent in arteries in your legs  
 
 
 
Yes / No / Don’t know  
 
 
 
 
 
 
 
    
 
 
2. a) Has your doctor ever told you that you have angina?  
 
 
Yes / No / Don’t know 
b) Do you have a history of chest pain/discomfort brought on  
     by exertion and relieved by rest?  
 
 
 
 
Yes / No / Don’t know 
 
   c) Do you have a history of chest pain relieved by medication?  
 
Yes / No / Don’t know 
 
What medication ?  
 
1- nitroglycerine  
2- other -name________________ 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 5 
 
3.  Have you ever had; 
a)  Heart stress test? 
 
 
 
 
 
Yes / No 
 
 
 
Was the result abnormal?   
 
 
 
Yes / No / Don’t know 
b)  Have you ever had a cardiac catheterization?  Yes / No 
 
 
 
Was the result abnormal?   
 
 
 
Yes / No / Don’t know 
 
8)  Have you ever had any surgical procedures? Yes/No 
 
 
If yes, what type: 
 
 
 
 
 
 
Date/Year: 
 
 
_____________________________________________________________________________ 
 
 
_____________________________________________________________________________ 
 
 
_____________________________________________________________________________ 
 
 
_____________________________________________________________________________ 
 
Medications and dietary supplements you are currently taking: 
 
Medication or Dietary Supplement: 
 
 
 
Dose, How Often, and Start Date: 
 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
    
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 
 
________________________________  
 
______________________________ 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 6 
 
Other Past Medical History Not Covered: 
Condition 
 
 
 
 
 
 
Year of diagnosis 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
 
Diet 
1.  Do you follow a specific diet?  
 
 
 
 
Yes / No 
 
a)  Ovo-lacto vegetarian (you do eat eggs, milk and cheese)? 
Yes / No 
 
b)  Vegan (you do not eat any animal products)? 
 
  
Yes / No 
c) other 
 
 
 
Yes / No 
If yes, please describe the diet? 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 
____________________________________________________________________________ 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 7 
 
18.5 Flyer for subject recruitment 
 
 
Doctors at the Institute for Translational Medicine and 
Therapeutics, University of Pennsylvania are studying  
the patterns of social behavior (recorded by cell phone use),  
blood pressure and metabolites in urine. 
 
or 
 
“Exploratory study to define circadian relationships between social behavior, blood 
pressure and metabolomics signatures.” 
 
If you are a healthy, non-smoking and non-pregnant 
individual between 18 – 65 years of age and own a smartphone,  
you may qualify for this RESEARCH study. 
 
Qualified participants will receive, at no cost: 
• Medical exams 
• Blood and urine tests 
• Compensation for your commitment based on eligibility 
 
Clinical Study Coordinator: Lavenia Banas 
 
For more information call: 215-662-4652 
 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
Circadian Research 
Study 215.662.4652 
 
 
 
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 8 
 
18.6 Physical Activity Questionnaire 
Physical Activity Questionnaire 
 
INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE 
(October 2002) 
 
LONG LAST 7 DAYS SELF-ADMINISTERED FORMAT 
 
FOR USE WITH YOUNG AND MIDDLE-AGED ADULTS (15-69 years) 
 
The International Physical Activity Questionnaires (IPAQ) comprises a set of 4 questionnaires. 
Long (5 activity domains asked independently) and short (4 generic items) versions for use by 
either telephone or self-administered methods are available. The purpose of the questionnaires is 
to provide common instruments that can be used to obtain internationally comparable data on 
health–related physical activity. 
 
Background on IPAQ 
The development of an international measure for physical activity commenced in Geneva in 
1998 and was followed by extensive reliability and validity testing undertaken across 12 
countries (14 sites) during 2000. The final results suggest that these measures have acceptable 
measurement properties for use in many settings and in different languages, and are suitable for 
national population-based prevalence studies of participation in physical activity. 
 
Using IPAQ  
Use of the IPAQ instruments for monitoring and research purposes is encouraged. It is 
recommended that no changes be made to the order or wording of the questions as this will affect 
the psychometric properties of the instruments.  
 
Translation from English and Cultural Adaptation 
Translation from English is encouraged to facilitate worldwide use of IPAQ. Information on the 
availability of IPAQ in different languages can be obtained at www.ipaq.ki.se. If a new 
translation is undertaken we highly recommend using the prescribed back translation methods 
available on the IPAQ website. If possible please consider making your translated version of 
IPAQ available to others by contributing it to the IPAQ website. Further details on translation 
and cultural adaptation can be downloaded from the website. 
 
Further Developments of IPAQ  
International collaboration on IPAQ is on-going and an International Physical Activity 
Prevalence Study is in progress. For further information see the IPAQ website.  
 
More Information 
More detailed information on the IPAQ process and the research methods used in the 
development of IPAQ instruments is available at www.ipaq.ki.se and Booth, M.L. (2000). 
Assessment of Physical Activity: An International Perspective. Research Quarterly for Exercise 
and Sport, 71 (2): s114-20. Other scientific publications and presentations on the use of IPAQ 
are summarized on the website. 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 9 
 
INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE 
 
We are interested in finding out about the kinds of physical activities that people do as part of 
their everyday lives. The questions will ask you about the time you spent being physically active 
in the last 7 days. Please answer each question even if you do not consider yourself to be an 
active person. Please think about the activities you do at work, as part of your house and yard 
work, to get from place to place, and in your spare time for recreation, exercise or sport. 
 
Think about all the vigorous and moderate activities that you did in the last 7 days. Vigorous 
physical activities refer to activities that take hard physical effort and make you breathe much 
harder than normal. Moderate activities refer to activities that take moderate physical effort and 
make you breathe somewhat harder than normal. 
 
PART 1: JOB-RELATED PHYSICAL ACTIVITY 
 
The first section is about your work. This includes paid jobs, farming, volunteer work, course 
work, and any other unpaid work that you did outside your home. Do not include unpaid work 
you might do around your home, like housework, yard work, general maintenance, and caring for 
your family. These are asked in Part 3. 
 
1. 
Do you currently have a job or do any unpaid work outside your home? 
 
 
 
Yes 
 
 
 
No 
 
Skip to PART 2: TRANSPORTATION 
 
The next questions are about all the physical activity you did in the last 7 days as part of your 
paid or unpaid work. This does not include traveling to and from work. 
 
2. 
 During the last 7 days, on how many days did you do vigorous physical activities like 
heavy lifting, digging, heavy construction, or climbing up stairs as part of your work? 
Think about only those physical activities that you did for at least 10 minutes at a time. 
 
_____ days per week 
 
 
No vigorous job-related physical activity 
Skip to question 4 
 
3. 
How much time did you usually spend on one of those days doing vigorous physical 
activities as part of your work? 
 
_____ hours per day 
_____ minutes per day 
 
4. 
Again, think about only those physical activities that you did for at least 10 minutes at a 
time. During the last 7 days, on how many days did you do moderate physical activities 
like carrying light loads as part of your work? Please do not include walking. 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 10 
 
 
_____ days per week 
 
 
No moderate job-related physical activity 
Skip to question 6 
 
5. 
How much time did you usually spend on one of those days doing moderate physical 
activities as part of your work? 
 
_____ hours per day 
_____ minutes per day 
 
6. 
During the last 7 days, on how many days did you walk for at least 10 minutes at a time 
as part of your work? Please do not count any walking you did to travel to or from 
work. 
 
_____ days per week 
 
 
No job-related walking 
Skip to PART 2: TRANSPORTATION 
 
7. 
How much time did you usually spend on one of those days walking as part of your 
work? 
 
_____ hours per day 
_____ minutes per day 
 
 
PART 2: TRANSPORTATION PHYSICAL ACTIVITY 
 
These questions are about how you traveled from place to place, including to places like work, 
stores, movies, and so on. 
 
8. 
During the last 7 days, on how many days did you travel in a motor vehicle like a train, 
bus, car, or tram? 
 
_____ days per week 
 
 
No traveling in a motor vehicle 
Skip to question 10 
 
9. 
How much time did you usually spend on one of those days traveling in a train, bus, car, 
tram, or other kind of motor vehicle? 
 
_____ hours per day 
_____ minutes per day 
 
Now think only about the bicycling and walking you might have done to travel to and from 
work, to do errands, or to go from place to place. 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 11 
 
 
10. 
During the last 7 days, on how many days did you bicycle for at least 10 minutes at a 
time to go from place to place? 
 
_____ days per week 
 
 
No bicycling from place to place 
Skip to question 12 
 
11. 
How much time did you usually spend on one of those days to bicycle from place to 
place? 
 
_____ hours per day 
_____ minutes per day 
 
12. 
During the last 7 days, on how many days did you walk for at least 10 minutes at a time 
to go from place to place? 
 
_____ days per week 
 
 
No walking from place to place 
Skip to PART 3: HOUSEWORK, 
HOUSE MAINTENANCE, AND 
CARING FOR FAMILY 
 
13. 
How much time did you usually spend on one of those days walking from place to place? 
 
_____ hours per day 
_____ minutes per day 
 
 
PART 3: HOUSEWORK, HOUSE MAINTENANCE, AND CARING FOR FAMILY 
 
This section is about some of the physical activities you might have done in the last 7 days in 
and around your home, like housework, gardening, yard work, general maintenance work, and 
caring for your family. 
 
14. 
Think about only those physical activities that you did for at least 10 minutes at a time. 
During the last 7 days, on how many days did you do vigorous physical activities like 
heavy lifting, chopping wood, shoveling snow, or digging in the garden or yard? 
 
_____ days per week 
 
 
No vigorous activity in garden or yard 
Skip to question 16 
 
 
15. 
How much time did you usually spend on one of those days doing vigorous physical 
activities in the garden or yard? 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 12 
 
 
_____ hours per day 
_____ minutes per day 
 
16. 
Again, think about only those physical activities that you did for at least 10 minutes at a 
time. During the last 7 days, on how many days did you do moderate activities like 
carrying light loads, sweeping, washing windows, and raking in the garden or yard? 
 
_____ days per week 
 
 
No moderate activity in garden or yard 
Skip to question 18 
 
17. 
How much time did you usually spend on one of those days doing moderate physical 
activities in the garden or yard? 
 
_____ hours per day 
_____ minutes per day 
 
18. 
Once again, think about only those physical activities that you did for at least 10 minutes 
at a time. During the last 7 days, on how many days did you do moderate activities like 
carrying light loads, washing windows, scrubbing floors and sweeping inside your 
home? 
 
_____ days per week 
 
 
No moderate activity inside home 
Skip to PART 4: RECREATION, 
SPORT AND LEISURE-TIME 
PHYSICAL ACTIVITY 
 
19. 
How much time did you usually spend on one of those days doing moderate physical 
activities inside your home? 
 
_____ hours per day 
_____ minutes per day 
 
 
PART 4: RECREATION, SPORT, AND LEISURE-TIME PHYSICAL ACTIVITY 
 
This section is about all the physical activities that you did in the last 7 days solely for 
recreation, sport, exercise or leisure. Please do not include any activities you have already 
mentioned. 
 
20. 
Not counting any walking you have already mentioned, during the last 7 days, on how 
many days did you walk for at least 10 minutes at a time in your leisure time? 
 
_____ days per week 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 13 
 
 
 
No walking in leisure time 
Skip to question 22 
 
21. 
How much time did you usually spend on one of those days walking in your leisure 
time? 
 
_____ hours per day 
_____ minutes per day 
 
22. 
Think about only those physical activities that you did for at least 10 minutes at a time. 
During the last 7 days, on how many days did you do vigorous physical activities like 
aerobics, running, fast bicycling, or fast swimming in your leisure time? 
 
_____ days per week 
 
 
No vigorous activity in leisure time 
Skip to question 24 
 
23. 
How much time did you usually spend on one of those days doing vigorous physical 
activities in your leisure time? 
 
_____ hours per day 
_____ minutes per day 
 
24. 
Again, think about only those physical activities that you did for at least 10 minutes at a 
time. During the last 7 days, on how many days did you do moderate physical activities 
like bicycling at a regular pace, swimming at a regular pace, and doubles tennis in your 
leisure time? 
 
_____ days per week 
 
 
No moderate activity in leisure time 
Skip to PART 5: TIME SPENT 
SITTING 
 
25. 
How much time did you usually spend on one of those days doing moderate physical 
activities in your leisure time? 
_____ hours per day 
_____ minutes per day 
 
PART 5: TIME SPENT SITTING 
 
The last questions are about the time you spend sitting while at work, at home, while doing 
course work and during leisure time. This may include time spent sitting at a desk, visiting 
friends, reading or sitting or lying down to watch television. Do not include any time spent 
sitting in a motor vehicle that you have already told me about. 
 
26. 
During the last 7 days, how much time did you usually spend sitting on a weekday? 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 14 
 
 
_____ hours per day 
_____ minutes per day 
 
27. 
During the last 7 days, how much time did you usually spend sitting on a weekend day? 
 
_____ hours per day 
_____ minutes per day 
 
 
This is the end of the questionnaire, thank you for participating. 
 
 
 
The source of this questionnaire is: www.ipaq.ki.se  
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 15 
 
18.7 Template Medical Monitoring 
 
Subject Binder: ID ___    ___    ___   (Initials ___    ___    ___ ) 
 
Medical Monitoring 
 
Lab Work 
 
Please specify which labs are being reviewed 
Screening 
 Close-out visit 
  Both 
 
 
1. Are all out-of-range values accounted for and reviewed by the investigator?  
Yes 
 No 
 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 
 
2. Are the ratings “Not Clinically Significant (NCS)” and “Clinically Significant 
(CS)”, when indicated, appropriate for the out-of-range values? 
Yes 
 No 
 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 
 
Adverse Events (AE) 
 
1. Are all Adverse Events accounted for and reviewed by the investigator? 
Yes 
 No 
   
N/A 
 (No AE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 16 
 
Subject Binder: ID ___    ___    ___   (Initials ___    ___    ___ ) 
 
2. Do all Adverse Events have a corresponding completed adverse event form? 
Yes 
 No 
   
N/A 
 (No AE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
3. Has the overall study course for the subject for Adverse Events been reviewed? 
Yes 
 No 
   
N/A 
 (No AE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
4. Have Adverse Events been identified, investigated, reported, and all necessary 
follow-ups performed? 
Yes 
 No 
   
N/A 
 (No AE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
Serious Adverse Events (SAE) 
 
 
Please describe the serious adverse event and the action taken following event: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________________N/A 
 (No SAE occurred) 
 
1. Are all Serious Adverse Events accounted for and reviewed by the investigator? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
__________________________________________________________________ 
__________________________________________________________________ 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 17 
 
Subject Binder: ID ___    ___    ___   (Initials ___    ___    ___ ) 
 
2. Do all Serious Adverse Events have a corresponding completed Serious Adverse 
Events Form? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________ 
 
3. Has the IRB been notified within 5 calendar days of the SAE? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
4. Has the FDA been notified of SAE within 7 days if unexpected and life-
threatening, or fatal, and within 15 days if unexpected and not life-threatening? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
5. Has the overall study course for the subject for Serious Adverse Events been 
reviewed? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
6. Have Serious Adverse Events been identified, investigated, reported, and all 
necessary follow-ups performed? 
Yes 
 No 
   
N/A 
 (No SAE occurred) 
If “No”, Please Explain: 
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
 
Medical Monitor’s Name (print):  ___________________________ 
 
Medical Monitor’s Signature:  
___________________________ 
 
Date:  
 
 
 
___________________________ 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 18 
 
18.8 Sample subject Diary Recall Form 
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
Appendix Page 19 
 
 
 
 
 

Human Circadian Rhythmicity 
 
Version: July 11, 2014  
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18.9 Munich ChronoType Questionnaire (MCTQ) 
 
 
 
 
 

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18.10 No-Revisions Letter – Security and Privacy Impact Assessment 
 
 
 
 

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18.11 Security and Privacy Information Impact Assessment (SPIA) 
 
SPIA for Vendors 
 
Summary: 
 
Ginger.io Overview 
The vendor, Ginger.io, provides technology to harvest and integrate user data from smartphones to 
generate behavioral features about its users. Smartphones represent a rich source for user activity data.  
These social sensing data can be mined to identify patterns of social behavior. Changes therein enable 
researchers to make inferences about the health status of individuals, e.g. the decrease of social 
interactions during acute flu outbreaks. We wish to test in a small pilot study in healthy volunteers 
whether this social sensing technology can be implemented to explore relationships between circadian 
patterns of user activity, continuous blood pressure and metabolic signatures in urine samples. The social 
sensing technology might provide insight how to integrate quantitatively social behavior into exploring 
cardiovascular and metabolic functions influenced by the molecular clock. 
Temporal storage on participants’ smartphones using the mobile application ‘Ginger.io’ installed; 
Ginger.io Behavior Platform which refers to the mobile application (or app) and the web dashboard. The 
Web Dashboard refers to a web-­‐based study management system that allows investigators and stud y 
staff to monitor the data collection process (including passive data collection and survey completion), 
identify issues and analyze the data. 
The data collected through the device includes data such as call and sms logs (including call/sms time, 
call duration, sms length, and phone number), location and device usage. Private information such as 
actual content of voice calls or sms messages or emails is never read, recorded or transmitted. 
The data described above is encrypted and transmitted to the server over a secure 128-bit SSL 3.0 
connection using the HTTPS protocol. Extra care is taken to ensure that the request cannot be spoofed or 
imitated by an attacker through the use of unique keys that are generated dynamically for every API 
request through a unique identifier and client secret that is embedded inside the application and cannot 
be accessed by any user or application. 
The data is stored securely on the mobile device temporarily. At regular intervals, the application checks 
for an available connection to the WWW. If such a connection is available, the data is transmitted over a 
secure connection to the server and deleted from the device. If a connection is not available or if a 
transmission is not successful, the data continues to be stored on the device until it is transmitted 
successfully. Data is recorded in 10 min intervals and stored on the phone. Ginger.io attempts to upload 
every hour. 
Ginger.io linux-­‐based servers are protected using a firewall and access control lists (ACLs), and access 
is restricted to Ginger.io employees and contractors. Superuser activity and researcher activity on the 
server is logged for security and auditing. The servers are regularly updated and patched with latest 
security updates to ensure that there are no known threats.  These servers host the database where the 
data is stored. Linux-­‐based servers and access to the servers is restricted to a few users responsible 
for maintaining and testing the database. For additional security, all the data that has personally 
identifiable information about the participant  (such as e-mail) is stored in a separate database from the 
one that has the data collected from the users and data related to the studies. The passively collected 
data from the phones as well as the actively-reported survey information is stored in the second 
database. Phone numbers and other such private information stored in this database are anonymized by 
hashing over the identifiers so that there is no threat to privacy because the data is not human-readable 
anymore. 
 
For Vendor: 
1. Do you have a SAS 70 Type II certification or other third party certification of your information 
security controls?  How recently was the review performed?  How regularly are reviews 
performed?  Can we get a copy? 
 
We have not undergone certification by any third-party certification groups. However, 
we've successfully gone through rigorous security reviews with several major healthcare 

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organizations, and we regularly review our own security practices to ensure that they 
remain up-to-date.  
 
2. Do you have any certifications for any compliance frameworks such as FISMA, HIPAA, PCI, etc.?   
 
Ginger.io technology, security and privacy policies comply with HIPAA standards - such 
as encryption (SSL), system-user identifiers (login, passwords), high-end server security, 
frequent backups, strong privacy policies, and strong internal business and employee 
policies. All patient personal and health information that may be included in the Ginger.io 
database will be treated in compliance with all applicable laws and regulations. Additional 
security and privacy safeguards can be enabled upon request of the client. 
 
3. Please describe controls to address the threat of information being compromised by an external 
hacker or malicious software.   
Your response should refer where applicable to safeguards such as intrusion detection, anti-virus, 
firewalls, vulnerability scanning, penetration testing, encryption, authentication and authorization 
protections and policies, including those involving passwords, removal of unnecessary network 
services, limiting of administrative access, code review, logging, employee training and other 
relevant safeguards. 
 
General: 
Ginger.io has a standard Corporate Information Security Policy (CISP) and can provide 
details if needed.  In particular, Section 14 of our CISP outlines the different steps that 
occur as part of developing new features. Our change management protocol includes the 
following steps: 
● Customer requirements generation 
●  Feature­level specification  
●  User­experience mocks and review  
●  Code development  
●  Pre­commit code reviews  
●  Testing, including automated and manual  
●  Deployment to a staging environment  
●  Full release  
The Ginger.io application has been penetration-tested by partners as part of security 
reviews by other partners. 
Ginger.io’s servers are protected using TripWire as an IDS. 
For additional security, all the data that has personally identifiable information about the 
participant (such as e-mail) is stored in a separate database from the one that has the data 
collected from the users and data related to the studies. The passively collected data from 
the phones as well as the actively-reported survey information is stored in the second 
database. Phone numbers and other such private information stored in this database are 
anonymized by hashing over the identifiers so that there is no threat to privacy because 
the data is not human-readable anymore. 
 
Passwords: 
The rules to create passwords are as follows: A minimum  of 8 characters and two 
complexity cases are required. This is automatically enforced by the system. There are 
four possible complexity cases: small letters [a­z], capital letters [A­Z], numerals[0­9] and 
special characters[e.g. ­,#!] 
 
Currently, our system does not allow password policy changes on a per study basis. We 
do not currently lock accounts, but all failed logins are logged in our system in order to 
identify any malicious activity. 
 

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Mobile Device Security: 
The data is stored securely on the mobile device temporarily. At regular intervals, the 
application checks for an available connection to the WWW. If such a connection is 
available, the data is transmitted over a secure connection to the server and deleted from 
the device. 
 
Data security on the phone is handled at the OS level. At a high level, the data is encrypted 
at rest automatically, and each app is sandboxed from other apps in order to prevent 
unauthorized access. Once the data is successfully transmitted to the server, it is wiped 
from the device. 
 
 
4. Please describe controls to address the threat of information being intercepted in transit by 
unauthorized persons. 
Your response should refer where applicable to safeguards such as encryption during 
transmission, encrypting wireless traffic, physically securing devices in transit, network traffic 
segregation, and other relevant safeguards, and include descriptions of encryption protocols and 
algorithms used. 
Researchers and study staff have access to the web dashboard through an account on the 
site. Information pertaining to a study is only available to researchers and study staff 
associated with that study. Participants or researchers not involved in the study cannot 
access the data through the dashboard. Data accessed through the dashboard is also 
transmitted through 128-bit SSL 3.0 connection using the HTTPS protocol. HTTP access is 
disabled. 
 
 
5. Please describe controls to address the threat of information being mistakenly disclosed to 
unauthorized persons. 
Your response should refer where applicable to issues of awareness and training, removal of 
unnecessary data (electronic and paper), use of screen savers and lockouts, limiting storage of 
confidential data on remote devices, verification of identity of individuals requesting access, and 
other relevant safeguards that enforce “need to know”.  
Access to the web dashboard is granted to individual participants by researchers. They 
are provided an option to use the study participants’ name or a coded identifier as is 
suitable for their study protocol. The coded identifier (or name) is used to refer to the 
participant on the dashboard pages and in communication with the participants. 
 
6. Please describe controls to address the threat of information knowingly being misused by your 
workforce and contractors. 
Your responses should refer where applicable to issues of strong sanctions policy and practice, 
background checks, role-based access to information, oversight of data authorization by 
supervisor, terminating access to data for terminated employees and employees changing job 
functions, prohibition on sharing passwords, and other relevant safeguards. 
Section 4 of our CISP details employee responsibilities with respect to privacy of 
patient data. As part of on­boarding, the importance of this is stressed. Any violation 
of this policy is treated very seriously.  
 
 
7. Please describe controls to address the threat of physical theft or loss of data. 
Your responses should refer where applicable to policies on the storage of confidential data on 
laptops, PDAs, USB drives and other portable devices, encryption of data on portable devices, 

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two factor authentication, removal of unnecessary information, physical protection of desktops 
and servers, and other relevant safeguards. 
Data is stored on our servers which are hosted by third­party vendor Linode. Linode 
takes a number of steps to ensure physical security: Security at each facility is made 
up of several layers. There is either a manned checkpoint or keycard access to get into 
the building itself (in some places, even the parking lot). Once inside the building, 
there are several layers of physical security before actually reaching computer 
equipment, including biometric fingerprint, handprint, retina scan, key card, and PIN 
numbers. All equipment is in locked cages, so it requires an additional key, 
thumbprint, or keycard to get into the locked cage.  
 
 
8. Please describe controls to address community concerns regarding privacy practices. 
Your responses should refer where applicable to privacy statements, opt-in or opt-out 
consents, compliance with applicable privacy rules, and other relevant safeguards. 
Our goal at Ginger.io is to provide a platform for patients, health care providers, and 
researchers to collect and analyze data to better understand patients’ behavior in order to 
improve their health. We take our users’ privacy very seriously. Our philosophy rests on a 
few key principles of data ownership: 
1. Users own their data. They opt-in to the system, have control over the use of any data 
that is generated, and can request to have their data removed from the system.  
2. If data is shared, it is done in an aggregated and anonymous fashion. We are working 
with leading enterprise partners and academic researchers to explore ways of 
leveraging aggregate anonymous data to improve patient health. We respect the 
privacy and anonymity of our users and never share specific individual data unless 
explicitly asked by our users to do so or otherwise required by law.  
3. Users should get value in exchange for sharing their data.  
We have seen a great willingness amongst users to share their data to collectively 
advance the state of health care for themselves and for others. We are committed to 
continue working closely with the health and data communities to promote these 
innovations. For a complete copy of the Ginger.io privacy policy please download it from 
our website (http://ginger.io/). 
The data collected through the device includes data such as call and sms logs (including 
call/sms time, call duration, sms length, and phone number), location and device usage. 
Private information such as actual content of voice calls or sms messages or emails is 
never read, recorded or transmitted. 
 
9. Please describe controls to address the use, handling, protection and sharing of confidential data 
shared with subcontractors. 
Your responses should state any relevant relationships that may induce additional risk to the safe 
storage of sensitive data (such as outsourcing of key services, use of sub-contractors or cloud 
services for hosting, etc.) and refer where applicable to contractual safeguards and reviews of 
security programs / practices. 
Ginger.io has subcontracted Linode for data storage; please see safety specifications 
described in paragraph 7.  
 
10. Please describe controls to address threats to the availability of data based on inadequate 
business continuity procedures. 

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Your responses should refer to business continuity and disaster recovery plans and procedures, 
regular testing, routine data backups and offsite storage.   
Rotating backups are implemented weekly, monthly and daily through full server 
snapshots. Such precautionary measures make us more resistant to hardware/software 
failures as well as human errors by enabling us to revert to a previous state in case of any 
issues and ensuring that we do not lose any important data. 
 
18.12 Surveys delivered through the smartphone app Ginger.io 
 
18.12.1 
Ginger.io Demographic Questionnaire (only at download) 
Gender 
Male 
Female 
 
Age 
18-24 
25-34 
35-44 
45-54 
55-64 
64+ 
Ethnicity 
Hispanic or Latino 
Not Hispanic or Latino 
Race 
American Indian/ Alaska Native 
Asian 
Native Hawaiian or Other Pacific Islander 
Black or African American 
White 
Highest degree or level of school you completed 
Primary School 
High School 
Associate degree 
Bachelor's Degree 
Advanced Degree (ex. Master's, Professional, Doctorate) 
Marital Status 
Single, Never Married 
Married 
Separated 
Divorced 
Widowed 
18.12.2 
Ginger.io Sleep Questionnaire (daily in the morning) 
"How many hours did you sleep last night?"  
Alternatively, if the Ginger.io technology can provide this, the exact hours of in-bed and out-of-bed will be 
surveyed. Options to realize this on the smartphone include for example a free text entry or a dial.    
18.12.3 
Ginger.io App Satisfaction Questionnaire (only at completion) 
Choices to respond to questions below are: 
1 Strongly disagree 
2 
3 Neutral 

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4 
5 Strongly agree 
Question #1: Ginger.io surveys are easy to complete? 
Question #2: Completing a survey every day is not burdensome? 
Question #3: Overall, the Ginger.io experience is what I expected? 
Question #4: What motivates you to complete the Ginger.io surveys? 
Question #5: Please share any comments for your answers above or additional feedback: