Comparison of Postprandial Glycemic and Insulinemic Response to a Cookie With or Without Added Fibersym After Three Days of Pre-feeding: An Acute Double-blind, Randomized Controlled Clinical Trial
Phase: NA
Conditions: Postprandial Hyperglycemia
Sponsor: MGP Ingredients, Inc.

 
 
 
 
 
 
 
ClinicalTrials.gov registration number NCT04820322 
Brief title: Comparison of the Postprandial Glycemic and Insulinemic Response After a Fibersym 
Containing Cookie With a Control 
 
Final Protocol for MGP    GIL-1852               August 7, 2018 
 
Comparison of postprandial glycemic and 
insulinemic response to a Cookie with or without 
added Fibersym after three days of pre-feeding:  
An acute double-blind, randomized controlled 
clinical trial 
 
This protocol is CONFIDENTIAL and may not be shown to unauthorized persons without permission. 
 

 
 
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Comparison of postprandial glycemic and insulinemic response to a Cookie 
with or without added Fibersym after three days of pre-feeding:  An acute 
double-blind, randomized controlled clinical trial 
 
Protocol GIL-1852 
 
Investigator:  
 
Thomas M Wolever, MD, PhD 
Glycemic Index Laboratories, Inc  
Tel.: 1 416 861 9177 Fax: 1 416 769 7210 
E-mail: twolever@gilabs.com 
 
Site: 
 
 
 
Glycemic Index Laboratories, Inc  
 
 
20 Victoria Street, suite 300 
 
 
Toronto, on  
 
 
Canada M5C 2N8 
 
Site Contact:  
 
Alexandra L Jenkins, PhD 
 
 
 
 
Director of Research 
 
 
 
 
Glycemic Index laboratories 
 
 
 
 
Tel.: 1 416 861 9782  
 
 
 
 
E-mail: alexandrajenkins@gilabs.com 
 
Site Coordinator: 
 
Adish Ezatagha 
 
 
 
 
Clinical Research manager 
 
 
 
 
Glycemic Index laboratories 
 
 
 
 
Tel.: 1 416 861 0506 ext 208  
 
 
 
 
E-mail: aezatagha@gilabs.com 
 
 
Sponsor: 
 
 
MGP Ingredients 
 
 
 
 
100 Commercial St 
 
 
 
 
Atchison, KS 66002 
 
 
 
 
USA 
 
 
Sponsor Representative: 
Ody Maningat, PhD,  
 
 
 
 
VP Ingredients R&D and Chief Science Officer 
 
 
 
 
MGP Ingredients 
 
 
 
 
Tel.: 1 913.360.5419 
 
 
 
 
E-mail: ody.maningat@mgpingredients.com 

 
 
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Table of Content 
Table of Content ....................................................................................................................................... 3 
Study Synopsis .......................................................................................................................................... 5 
1. 
Background and Rationale ............................................................................................................... 9 
2. 
Study Objectives ............................................................................................................................. 10 
2.1 Primary objective .......................................................................................................................... 10 
2.2 Secondary objectives .................................................................................................................... 10 
3. 
Subject Selection ............................................................................................................................ 10 
3.1 Type and number of subjects ....................................................................................................... 10 
3.2 Inclusion Criteria ........................................................................................................................... 10 
3.4 Withdrawal Criteria ...................................................................................................................... 11 
4. 
Study Design and Procedures ......................................................................................................... 11 
4.1 Procedures .................................................................................................................................... 12 
4.2 Study Flow Chart ........................................................................................................................... 13 
4.3 Test Foods ..................................................................................................................................... 13 
4.4 GI Tolerability ............................................................................................................................... 14 
4.6 Satiety ........................................................................................................................................... 14 
4.6 Randomization .............................................................................................................................. 15 
4.7 Subject Recruitment ..................................................................................................................... 15 
4.6 Selection of participants ............................................................................................................... 15 
4.7 Biochemical Analysis ..................................................................................................................... 15 
5. Data Analysis ...................................................................................................................................... 16 
5.1 Calculations................................................................................................................................... 16 
5.2 Statistical Analysis ........................................................................................................................ 16 
6. Study Product ..................................................................................................................................... 16 
6.1 Blinding, Packaging and Labelling (Ody – we will do this) ............................................................ 16 
6.2 Dispensing ..................................................................................................................................... 17 
7. Ethical Issues ....................................................................................................................................... 17 
7.1 Informed Consent ......................................................................................................................... 17 
7.2 Confidentiality .............................................................................................................................. 17 
7.3. Participant Withdrawal Criteria ................................................................................................... 17 
7.4 Adverse Event Reporting .............................................................................................................. 18 

 
 
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7.5 Risks .............................................................................................................................................. 19 
7.6 Dispensing ..................................................................................................................................... 19 
7.7 Source documents and archiving ................................................................................................. 19 
8. Study Management ............................................................................................................................ 19 
8.1 Source documents and archiving ................................................................................................. 19 
Appendix  1– Fibersym Nutritional Data ............................................................................................ 21 
Appendix 2: Physical Comfort Questionnaire ..................................................................................... 23 
Appendix 3: Satiety Questionnaire ..................................................................................................... 24 
 

 
 
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Study Synopsis 
STUDY TITLE: 
Comparison of postprandial glycemic and insulinemic response to a 
Cookie with or without added Fibersym after three days of pre-
feeding:  An acute, double-blind, randomized controlled clinical trial  
STUDY NUMBER/ 
VERSION DATE: 
GIL-1852; version: June 31, 2018 
INVESTIGATORS: 
GI Labs: Thomas Wolever, MD, PhD; Alexandra Jenkins, PhD
 
SPONSOR:  
MGP Ingredients, Inc, 
Contact: Ody Maningat, PhD, VP Ingredients R&D and Chief Science 
Officer 
STUDY SITE: 
Glycemic Index Laboratories, Inc. (GI Labs) 
STUDY OBJECTIVE(S): 
Primary Objective: to compare the postprandial glucose incremental 
are under the curve (IAUC) after the Fibersym containing carbohydrate 
load with the glucose IAUC after the control meal 
INTERVENTION 
PRODUCT 
Fibersym® is a resistant modified wheat starch in which over 85% of 
the total starch is resistant starch as measured by AOAC method 
991.43. Fibersym can easily be added to food formulations as it 
provides a smooth texture, neutral flavour and white color.  
STUDY POPULATION  
Healthy adult males or females (n=15), aged 18-75 years with BMI 
between 18.5 and 35 kg/m2. Each subject will have to fulfill all 
inclusion criteria and will not be allowed to meet any of the exclusion 
criteria. 
TEST MEALS:  
1. Control Cookie
2. Cookie with added Fibersym  
The difference in the cookies is the presence of the Fibersym, meals 
will therefore be matched for available carbohydrate. 
STUDY DESIGN AND 
RATIONALE 
Design: acute, double blind, randomized, controlled clinical trial.
Subjects will come in fasting and be given either the Control or 
Fibersym containing cookie. Postprandial glucose and insulin levels will 
be measured over 2 hours.  
As Fibersym is recommended to be consumed on a daily basis, for 3 
days prior to each test meal visit, subjects will be given cookies to be 
consumed 3 times daily for 3 days, ie control cookies will be consumed 
for 3 days before the control cookie test meal and Fibersym cookies 

 
 
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before the Fibersym cookie test meal. Each subject will be provided 
with enough cookies to consume 1 cookie with each meal (breakfast, 
lunch and dinner) over the 3 days. The Fibersym containing cookie will 
deliver about 29g/day of dietary fibre. 
PROTOCOL SUMMARY 
Participants will be recruited by GI labs from their existing subject pool 
through email and/or advertising posters and leaflets. Volunteers will 
have the study explained to them prior to providing informed consent. 
 
Visit 1: Screening:  A pre-study examination will verify that subjects 
qualify for study inclusion. A number of parameters will be assessed: 
including blood pressure; weight, height, BMI, and brief medical 
history.  
 
Visit 2-3: Eligible subjects will be randomized using an online 
randomization calculator. Eligible subjects will be studied on 2 
separate days over a period of 4 weeks or less. Prior to each test meal 
they will be provided with enough cookies to consume 3 times/day 
over 3 days and instructed to start consuming these 3 days before 
their visit.  They will also be provided with a calorie appropriate, 
standard dinner to be consumed on the evening before their test meal 
The interval between successive tests will be no less than 6 days and 
no more than 4 weeks.  
On each test day, participants will come to GI Labs in the morning after 
a 10-12h overnight fast (except for water).  Participants will be asked 
to maintain stable dietary and activity habits throughout their 
participation and refrain from drinking alcohol and from unusual levels 
of food intake or physical activity for 24h before each test. Before the 
start of the test meal, subjects will be asked whether they consumed 
the provided cookies over the last 3 days as instructed and the 
standard dinner the evening before.  Subjects will be asked to 
complete a 3d dietary food record and symptom diary before each test 
visit. If any subject is not feeling well or has not complied with the 
preceding experimental conditions, the test will not be carried out and 
will be rescheduled for another day. On each test day, two fasting 
fingerprick blood samples will be collected at -5min and 0min. 
Questionnaires to record satiety and GI symptoms will be 
administered. Participants will then be given the test food together 
with 250ml of water and instructed to consume this over 15minutes.  
Additional blood samples will be collected 15, 30 46, 60, 90 and 
120min after the start of the test meal. Satiety Questionnaires will be 
administered at the same time intervals. GI symptom questionnaires 

 
 
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will be filled out at 2h in addition to fasting.
CRITERIA FOR 
EVALUATION: 
EFFICACY: Primary outcome is comparison of the glucose IAUC of the 
Fibersym meal with the control meal.  
Secondary outcomes: comparison of the insulin (IAUC) of the Fibersym 
meal with the control meal, comparison of glucose and insulin levels at 
each time point and satiety scores at each time point.   
SAFETY: Adverse events. 
STATISTICAL 
METHODS: 
Results for all foods in a series will be compared by GLM ANOVA. After 
demonstrating significant heterogeneity, the significance of the 
differences will be tested using Tukey method to adjust for multiple 
comparisons  
Ethics Board Approval
The investigator will be responsible for submission of the study to the 
Western Institutional Research Board. Prior to submission of the 
application, the sponsors and all co-investigators will be given the 
opportunity to review the application. Submission of the application 
will only take place if all parties agree. The Western Institutional 
Review Board® meets all requirements of the US Food and Drug 
Administration (FDA), the Department of Health and Human Services 
(DHHS), the Canadian Health Protection Branch (HPB), Canadian 
Institutes of Health Research (CIHR) and the European Community 
Guidelines.  Participants will not be enrolled into the study until they 
have had the study procedures explained to them, had a chance to ask 
questions, and given their voluntary consent by signing the consent 
form.  Participants who do not understand English will not be enrolled. 
Subject Selection 
Criteria 
Inclusion criteria: 
1. Male or non-pregnant females, 18-75 years of age, inclusive 
2. Body mass index (BMI) between 18.5 and 35 kg/m² inclusive at 
screening. 
3. Systolic blood pressure < 130mmHg, Diastolic Blood pressure 
<90mmHg. 
4. Willing to maintain habitual diet, physical activity pattern, and 
body weight throughout the trial. 
5. Subject is willing to abstain from strenuous exercise, or 
consume alcoholic drinks 24hours before study days. 
6. Absence of health conditions that would prevent fulfillment of 
study requirements as judged by the Investigator on the basis 

 
 
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of medical history.
7. Understanding the study procedures and willing to provide 
informed consent to participate in the study and authorization 
to release relevant protected health information to the study 
investigator. 
8. Female subjects are willing to use a contraceptive method to 
avoid pregnancy during the study period.  
 
Exclusion criteria: 
1. Failure to meet any one of the inclusion criteria 
2. Smokers 
3. Known history of diabetes, gastrointestinal, liver, kidney, or 
cardiovascular (including, but not limited to, atherosclerotic 
disease, history of myocardial infarction, peripheral arterial 
disease, stroke), and pulmonary disease 
4. Use of medications known to influence carbohydrate metabolism, 
including, but not limited to adrenergic blockers, diuretics, 
thiazolidinediones, metformin and systemic corticosteroids within 
4 weeks of the screening visit, or with any condition which might, 
in the opinion of Dr. Wolever either: 1) make participation 
dangerous to the subject or to others, or 2) affect the results.  
5. Use of antibiotics within 4 weeks of start of study  
6. Major trauma or surgical event within 3 months of screening. 
7. Unwillingness or inability to comply with the experimental 
procedures and to follow GI Labs safety guidelines. 
8. Known intolerance, sensitivity or allergy to any ingredients in the 
study products.  
9. Extreme dietary habits, as judged by the Investigator (i.e. Atkins 
diet, very high protein diets, etc). 
10. Change in body weight of >3.5kg within 4 weeks of the screening 
visit. 
11. History of cancer in the prior two years, except for non-melanoma 
skin cancer. 
12. Exposure to any non-registered drug product within 30 d prior to 
screening. 
13. Pregnancy or breastfeeding 
14. Any history of an eating disorder (e.g., anorexia nervosa, bulimia 
nervosa, binge eating) diagnosed by a health professional 
 
 

 
 
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1. Background and Rationale 
Consumption of whole grains have been recommended by most health agencies to increase dietary 
fibre intake with the ultimate goal to help maintain a healthy body weight and improve insulin 
sensitivity.  Despite these recommendations, most individuals do not meet the recommended 25–
35 g per day. Therefore, innovative ideas to increase dietary fibre intake are needed. One approach is 
to incorporate either by substituting the carbohydrate in a food or by adding isolated fibers to 
products. MGP Ingredients had developed several resistant starches including, Fibersym® RW, a 
resistant starch 4 (RS4), which are easily incorporated into foods and would help increase the dietary 
fiber content of food products, however, RS4 is not included among the eight dietary fibre sources 
recently approved by FDA.    
 
The FDA defines dietary fiber as “non-digestible soluble and insoluble carbohydrates (with 3 or more 
monomeric units), and lignin that are intrinsic and intact in plants; isolated or synthetic non-digestible 
carbohydrates (with 3 or more monomeric units) determined by FDA to have physiological effects 
that are beneficial to human health." The list of currently approved fibers under the new FDA food 
labeling regulations that has a compliance date of January 1, 2020 includes RS2 but not RS4.  
Clinical research studies have demonstrated a broad range of health benefits after consumption of RS 
including attenuation of postprandial blood glucose and insulin levels, improving the profile of the 
microbiota, reduction in colon cancer and increased fat oxidation and mineral absorption (Higgins et 
al, 2004; Jenkins et al, 1998, 2000; Robertson et al, 2005; So et al, 2007, Topping et all, 2003).    
Several different forms of RS have been developed, these include RS1 which is composed of starch 
granules embedded in indigestible plant material, RS2 is native granular starch with a B-type x-ray 
pattern, RS3 is crystallized starch and maltodextrins made by alternate cooking/cooling processes on 
starchy materials and finally, RS4 is chemically modified starch typically through esterification, 
crosslinking or transglycosylation.  
 
The majority of the studies demonstrating a reduction in postprandial glucose and insulin levels kept 
the total carbohydrate of the meals the same, ie they achieved the attenuation of the glucose by 
substituting the available carbohydrate with the resistant starch (Haub et al, 2010) but not all (Al-
Tamimi et al, 2010). The last trial suggests that RS4xl may differ from the other RS in that it may be 
inherently physiologically active itself, not unlike the viscous fibres.   
 
Fibersym® is a resistant modified wheat starch in which over 85% of the total starch is resistant starch 
as measured by AOAC method 991.43. Fibersym can easily be added to food formulations as it 
provides a smooth texture, neutral flavour and white color. It is meant to be consumed on a regular 
basis and doses up to 40g/day can be tolerated. The effect of the Fibersym containing products on 
postprandial glucose and insulin levels when compared to a control meal containing the same 
amount of available carbohydrate is not known. This study therefore investigates the effect of the 
acute effect of control or Fibersym cookie matched for available carbohydrate after 3 day 
habituation.    
 

 
 
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2. Study Objectives 
2.1 Primary objective 
 
To compare the 2 hour postprandial glucose incremental area under the curve (IAUC) after 
the Fibersym containing carbohydrate load with the control meal  
 
2.2 Secondary objectives 
 
To compare the 2hour postprandial insulin incremental area under the curve (IAUC) after the 
Fibersym containing carbohydrate load with the control meal  
 
To compare the individual postprandial glucose and insulin responses at each time point after 
the Fibersym containing carbohydrate load with the control meal 
 
To compare the GI symptoms after the three days of pre-feeding of Fibersym cookies with the 
control meal 
 
To compare the satiety scores after the Fibersym containing carbohydrate load with the 
control meal 
 
SAFETY: GI symptoms and Adverse events. 
 
 
3. Subject Selection 
3.1 Type and number of subjects 
Fifteen (15) healthy adult males or non-pregnant females recruited from the pool of subjects who 
have previously participated in studies at GI Labs and have given permission to be contacted to be 
recruited for future studies or using online advertising and/or posters. Each subject will have to fulfill 
all inclusion criteria and will not be allowed to meet any of the exclusion criteria. 
 
  3.2 Inclusion Criteria  
 
Male or non-pregnant females, 18-75 years of age, inclusive 
 
Body mass index (BMI) between 18.5 and 35 kg/m² inclusive at screening. 
 
Systolic blood pressure < 130mmHg, Diastolic Blood pressure <90mmHg. 
 
Willing to maintain habitual diet, physical activity pattern, and body weight throughout the trial. 
 
Subject is willing to abstain from strenuous exercise, or consume alcoholic drinks 24hours before 
study days. 
 
Absence of health conditions that would prevent fulfillment of study requirements as judged by 
the Investigator on the basis of medical history. 
 
Understanding the study procedures and willing to provide informed consent to participate in the 
study and authorization to release relevant protected health information to the study 
investigator. 

 
 
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 
Female subjects are willing to use a contraceptive method to avoid pregnancy during the study 
period.  
 
3.3 Exclusion Criteria  
 
Failure to meet any one of the inclusion criteria 
 
Smokers 
 
Known history of diabetes, gastrointestinal, liver, kidney, or cardiovascular (including, but not 
limited to, atherosclerotic disease, history of myocardial infarction, peripheral arterial disease, 
stroke), and pulmonary disease 
 
Use of medications known to influence carbohydrate metabolism, including, but not limited to 
adrenergic blockers, diuretics, thiazolidinediones, metformin and systemic corticosteroids within 
4 weeks of the screening visit, or with any condition which might, in the opinion of Dr. Wolever, 
the president of GI Testing, either: 1) make participation dangerous to the subject or to others, or 
2) affect the results.  
 
Use of antibiotics within 4 weeks of start of study  
 
Major trauma or surgical event within 3 months of screening. 
 
Unwillingness or inability to comply with the experimental procedures and to follow GI Labs 
safety guidelines. 
 
Known intolerance, sensitivity or allergy to any ingredients in the study products.  
 
Extreme dietary habits, as judged by the Investigator (i.e. Atkins diet, very high protein diets, etc). 
 
Change in body weight of >3.5kg within 4 weeks of the screening visit. 
 
History of cancer in the prior two years, except for non-melanoma skin cancer. 
 
Exposure to any non-registered drug product within 30 d prior to screening. 
 
Pregnancy or breastfeeding 
 
Any history of an eating disorder (e.g., anorexia nervosa, bulimia nervosa, binge eating) 
diagnosed by a health professional 
 
3.4 Withdrawal Criteria 
 
Withdrawal of consent for any reason 
 
During the course of the study, the development of an injury or illness or initiation of use of a 
medication which, in the opinion of Dr. Wolever, makes the subject's continued participation 
dangerous to the subject or to others, or which may affect the results. 
 
Failure to follow GI Labs safety guidelines 
 
Repeated failure to attend at scheduled visits 
 
Repeated failure to follow the protocol 
 
 
4. Study Design and Procedures 
The study is double-blind with a randomized, cross-over design. 

 
 
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4.1 Procedures  
Visit 1: Participants willing to be considered will be invited to come to the research centre to have the 
study procedures explained to them and be given a copy of the consent form which they may either 
sign then, take away to sign at a later date, or decline to participate. Participants will be encouraged 
to ask any questions they may have and not to sign the consent form until all of their questions have 
been answered to their satisfaction. Those who consent to participate will come to the research 
centre for a pre-selection visit when subject eligibility will be determined.  A number of parameters 
will be assessed: including blood pressure; weight, height, BMI, and brief medical history.  
 
Visit 2-3: Eligible subjects will be randomized using an online randomization calculator. Eligible 
subjects will be studied on 2 separate days over a period of 4 weeks or less. Prior to each test meal 
they will be provided with enough cookies to consume 3 times/day over 3 days and instructed to start 
consuming these 3 days before their visit.  They will also be provided with a calorie appropriate, 
standard dinner to be consumed on the evening before their test meal. The interval between 
successive tests will be no less than 6 days and no more than 4 weeks. On each test day, participants 
will come to GI Labs in the morning after a 10-12h overnight fast (except for water).  Participants will 
be asked to maintain stable dietary and activity habits throughout their participation and refrain from 
drinking alcohol and from unusual levels of food intake or physical activity for 24h before each test. 
Before the start of the test meal, subjects will be asked whether they consumed the provided cookies 
over the last 3 days as instructed and the standard dinner the evening before.  Subjects will be asked 
to complete a 3d record of supplement consumption and whether they consumed the standard 
evening meal, in addition to a 3d symptom diary before each test visit. If any subject is not feeling 
well or has not complied with the preceding experimental conditions, the test will not be carried out 
and will be rescheduled for another day. On each test day, two fasting fingerprick blood samples will 
be collected at -5min and 0min. Each sample will consist of 2 vials, one for glucose analysis and one 
for insulin analysis (4—8 drops of blood each). Questionnaires to record satiety and GI symptoms will 
be administered. Participants will then be given the test food together with 250ml of water and 
instructed to consume this over 15minutes.  Additional blood samples will be collected 15, 30 46, 60, 
90 and 120min after the start of the test meal. Satiety Questionnaires will be administered at the 
same time intervals. GI symptom questionnaires will be filled out at 2h in addition to fasting. 
 

 
 
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4.2 Study Flow Chart 
 
Visits 
 
 
Procedures 
Screening  
 
TEST VISITS 
 
V1  
 
3 day  
prefeeding 
 
V2 
Test meal 
7 day  
wash out 
3 day  
prefeeding 
 
V3 
Test meal 
Informed Consent Process and 
Informed Consent Form 
Signature 
X 
 
 
 
 
 
Subject’s demographic data 
X 
 
 
 
 
 
Inclusion and exclusion criteria 
X 
 
 
 
 
 
Subject’s eligibility 
X 
 
 
 
 
 
Anthropometry  
X 
 
X 
 
 
X 
Check of dietary compliance  
 
X 
X 
 
X 
X 
Record of supplement 
consumption  
 
X 
 
 
X 
 
Check of concomitant 
medications   
X 
 
X 
 
 
X 
2 Fasting blood samples 
 
 
X 
 
 
X 
Consumption of test food 
 
 
X 
 
 
X 
Postprandial blood samples 15, 
30, 45, 60, 90 and 120min  after 
starting to eat 
 
X 
X 
 
X 
X 
GI Symptom Questionnaire 
 
X 
X 
 
X 
X 
Satiety Questionnaire 
 
 
X 
 
 
X 
Check of adverse events 
X 
 
X 
 
X 
X 
 
 
 
4.3 Test Foods  
There will be two test foods: 
1. 
Control Cookie 
2. 
Cookie with added Fibersym  
The difference in the cookies is the presence of the Fibersym, meals will therefore be matched for 
available carbohydrate. Both test meals will be consumed with 250ml of water. 
During the 3-day pre-feeding period, subject will consume 9 cookies per day with the aim to provide 
approximately 29g of fibre per day from the Fibersym cookies. For the test breakfasts, the subject will 
consume approximately 3 cookies containing 50g available carbohydrate. The Fibersym cookies will 

 
 
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deliver approximately 10g of fibre. Once the cookies are baked they will be sent out for 
macronutrient analysis and the final weight of the cookies fed will be adjusted accordingly. 
Table 1: Approximate composition of the test meals* 
Approx. 
# 
cookies 
Weight
(g) 
Protein
(g) 
Fat
(g) 
Total 
carbohydrate 
(g) 
Dietary 
Fibre 
(g) 
Available 
carbohydrate
(g) 
Control 
Cookie 
 
3 
90 
3.4 
10.5 
50.2 
0.2 
50 
Fibersym 
cookie 
 
3 
100 
3.4 
10.5 
60.2 
10.2 
50 
* Once the cookies are baked they will be sent out for macronutrient analysis and the final weight of 
the cookies fed will be adjusted accordingly. 
 
 
4.4 Standard Evening meal 
All subjects will be asked to consume a standard evening meal which will be provided by GI Labs and 
consist of a frozen dinner, eg Stouffers Teriyaki Chicken bowl 
4.5 GI Tolerability 
GI tolerability will be assessed using a Physical Comfort Questionnaire (Appendix 2). Subjects will be 
asked to complete the Questionnaire before they start consuming the test food and every day during 
the 3 day pre-feeding period. During the test day, they will fill it out before consuming the test 
breakfast at 0min and again at 2h.  
Participants mark either “yes” or “no” after each marker of physical comfort.  If they mark “yes” they 
are instructed to rate the severity of the side-effect on a 100 mm VAS and to provide any comments 
they feel are necessary.  The physical comfort scale includes bloating, belching, diarrhea, flatulence, 
nausea, headache, and a category for “other”.  In the “other” category, participants will be asked to 
specify what they mean by “other” and rate the severity using the 100 mm line.   
4.6 Satiety 
Subjective measurements of palatability, motivation to eat and physical comfort will be assessed 
using visual analog scales (VAS) (Appendix 3) at the same time points blood samples are collected.  
Each of the questions on the VAS is a 100 mm line anchored at each end with opposing statements 
(Rogers and Blundell 1979).  For instance, fullness is assessed with the following statement on the left 
side of the line “not full at all” with the following statement to the right side of the line “As full as I 

 
 
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have ever felt”.  Participants make a vertical mark on the line at a point that they felt reflects their 
feelings at the moment the test was taken.  Scores will be assessed by measuring the distance 
between the intersection of the mark on the line and the left end of the line (see Appendix 3).  
The Motivation to Eat questionnaire includes 4 questions: 
Q1: How strong is your desire to eat? (“very weak” to “very strong”) 
Q2: How hungry do you feel? (“not hungry at all” to “as hungry as I have ever felt”) 
Q3: How full do you feel? (“not full at all” to “as full as I have ever felt”)  
Q4: How much do you think you could eat now? (“nothing at all” to “a large amount”) 
Average appetite score is calculated as a summary measure using the following equation: 
Average appetite = [Q1 + Q2 + Q4 + (100 – Q3)] 4 
Since Question 3 assesses fullness, it has opposite anchors at each end of the 100 mm line compared 
to the other 3 questions.  Therefore, Q3 is subtracted from 100 in the equation to adjust for this 
difference.  
4.7 Randomization  
Eligible subjects will be randomized using an online randomization calculator. Orders will be assigned 
to subjects in the order they attend the first visit after being recruited. 
 
4.8 Subject Recruitment 
Participants will be recruited from the pool of participants at GI Laboratories who have indicated that 
they are willing to be contacted and asked if they wish to participate in new studies or through online 
advertisements and posters. 
 
4.9 Selection of participants 
The procedure for obtaining informed consent is described in Section 7.1. Volunteers who 
consent to participate will come to the research centre for a pre-selection visit when subject 
eligibility will be determined. 
 
4.10 Biochemical Analysis (note the biochemical analysis method for glucose analysis may 
change) 
Blood collection tubes will be labeled with the subject’s ID, visit date, test meal code, GI Labs protocol 
number (GIL-1852) and time of collection. After blood collection the tubes containing blood for 
glucose analysis will be rotated to mix the blood with the anti-coagulant and then placed in a 
refrigerator until the last blood sample in the set has been collected; after 3 hours the set of 10 tubes 
will be bundled together with a rubber band and placed in a -20°C freezer until analysis which will be 
performed within 3 days. Glucose analysis will be performed within 5 days using either the Vitros 350 
Chemistry System (Vitros 350 Chemistry System, Ortho Clinical Diagnostics, Raritan, NJ) or a YSI 2300 
Stat glucose/lactate analyser (YSI, Inc. Yellow Springs, OH).  Analytical coefficient of variation (CV) for 

 
 
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glucose will be calculated by measuring the 0min sample 2 times; typical values range for analytical 
CV for glucose in our hands is <2%. 
 
The microvette tubes containing blood for insulin will be left a room temperature to allow the blood 
to clot, centrifuged and the serum transferred to labeled polypropylene tubes and stored at -20°C 
prior to analysis of insulin. Insulin levels will be measured using the Human Insulin EIA Kit (Alpco 
Diagnostics, catalog # 80-INSHU-E10.1ii). The typical CV for serum insulin in our hands is about 7%. 
 
5. Data Analysis 
5.1 Calculations 
The incremental areas under the blood glucose and serum insulin response curves (iAUC), ignoring 
area below fasting, will be calculated using the trapezoid rule (Wolever et al, 1986, 2004). Fasting 
glucose and insulin will be taken to be the mean of the concentrations in the 2 fasting samples.  
GI symptoms and Satiety calculations – to be added 
 
5.2 Statistical Analysis 
No interim analyses are planned.  All summaries of demographics, baseline characteristics, efficacy 
and safety will be performed after all subjects complete both periods and the data collection and 
query processes are finalized. 
 
Descriptive Statistics:  All continuous data will be summarized by number of subjects assessed, mean, 
standard deviation (SD), median and range (minimum and maximum values).  Demographic and 
baseline characteristics to be summarized include gender; ethnicity; height (m); weight (kg); body 
mass index (BMI) (kg/m2) and blood pressure (mmHg).  
 
Data will be analyzed using General Linear Model analysis of variance (GLMANOVA). After 
demonstration of significant heterogeneity, the individual means will be compared using Tukey’s test 
to adjust for multiple comparisons. The criterion for statistical significance will be a 2-tailed p<0.05. 
 
6. Study Product 
6.1 Blinding, Packaging and Labelling  
The product label will display the subject number, subject initials, product ID, ingredients statement, 
GIL repacked date, expiration date, researcher name and telephone number, 
investigational use statement, and allergy warnings (if needed). Study Product Intake Logs will be 
completed upon dispensation of study product to each subject. 
 

 
 
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6.2 Dispensing 
It is the responsibility of the Investigator or his designee to ensure that study product is only provided 
to study participants. The specific serving size for each product will be provided to each subject. 
 
7. Ethical Issues 
7.1 Informed Consent 
The investigator will be responsible for submission of the study to the Western Institutional Research 
Board. Prior to submission of the application, the sponsor will be given the opportunity to review the 
application. Submission of the application will only take place if both parties agree. The Western 
Institutional Review Board® meets all requirements of the US Food and Drug Administration (FDA), 
the Department of Health and Human Services (DHHS), the Canadian Health Protection Branch (HPB), 
Canadian Institutes for Health Research (CIHR) and the European Community Guidelines. Participants 
will not be enrolled into the study until they have had the study procedures explained to them, had a 
chance to ask questions, and given their voluntary consent by signing the consent form. Participants 
who do not understand English will not be enrolled. 
 
7.2 Confidentiality 
Information from the studies may be submitted to the sponsor for its use, and may be sent to the 
Canadian Therapeutic Products Directorate (TPD) and to the U.S. Food and Drug Administration 
(FDA), Department of Health and Human Services and the Western International Review Board® 
(WIRB®). Because of the need to release information to these parties, absolute confidentiality cannot 
be guaranteed. The results of this research study may be presented at meetings or in publications; 
however, subject identity will not be disclosed in those presentations. 
 
7.3. Participant Withdrawal Criteria 
The Investigator may elect to withdraw the participant from the study or the participant may 
withdraw from the study at any time.  Reasons for withdrawing include, but are not limited to: 
 
Study product never consumed 
 
 
Participant was lost to follow-up  
 
Participant did not follow study procedures  
 
Participant elected to withdraw from the study for any reason 
 
Investigator elected to remove participant from the study for any reason 
 
Subject takes longer than the specified time to complete the study 
 
In the case of premature withdrawal, all planned assessments for the end of the study visit will be 
completed. The subject’s CRF will be completed including the final assessment. The date and main 
reason for the premature withdrawal will be clearly documented in the subject’s file and written 
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7.4 Adverse Event Reporting 
An adverse event is any symptom, injury, illness, or medical/surgical procedure whether planned or 
not or whether associated with the study foods or not.  Adverse events will be assessed at each visit 
and recorded in the Case Report Forms. Adverse events will be evaluated for duration, severity, 
seriousness, and causal relationship to the food items provided in the study by the study physician 
who will decide if any action is required and provide referral, treatment, and/or follow-up as 
appropriate until resolved, judged to no longer be clinically significant, or if a chronic condition, until 
fully characterized.  Research staff will record the final outcome and resolution date of the event 
wherever possible. The action taken and the outcome will be recorded in the Case Report Form. 
 
 
It is anticipated that participants enrolled in the study will be clinically managed without the 
need to add medications or to change the dosage(s) assigned to their current medications.  In 
the event that additional medication is required, or an increase in their medication dosage is 
warranted, these changes will be recorded as adverse events.   
 
 
Investigators are required to report adverse events that fit the following criteria within 10 
working days of the time the investigator becomes aware of them: 
 
 
Event is Unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-approved 
research protocol and informed consent document, or the Investigator Brochure; and (b) the 
characteristics of the subject population being studied. 
 
Related or possibly related to participation in the research (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); and 
 
Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
If the adverse event is clearly not related to the study drug, device, procedures, or washout process, it 
would not represent a risk to other subjects in the research or a “problem” for the study and, 
therefore, does not have to be reported to WIRB. 
The Principal Investigator, Dr. Thomas Wolever, will be informed within 48 hrs of the nature of the 
reportable AE and the treatment allocation of the participant in whom it occurred by sending a copy 
of the AE report via email (thomas.wolever@utoronto.ca).   

 
 
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7.5 Risks 
No adverse events related to ingestion of the RS4 tested in this study have been reported. However, 
there may be rare occurrences of study product intolerance, as manifested by gastrointestinal 
symptoms (such as crampy gas, bloating, or watery stools), eczema, rashes, or other signs of allergy. 
7.6 Dispensing 
It is the responsibility of the Investigator or his designee to ensure that study product is only provided 
to study participants.   
7.7 Source documents and archiving 
All documents relating to the study will be kept by the investigator: the original informed consent 
form, source documents, copy of the CRF, copy of the accountability of products administered, copy 
of the WIRB (ethics committee) approval and correspondence with the partner.  The investigator will 
authorize direct access to the source documents during monitoring.  As required by Canadian law, 
documents will be kept by the investigator for at least 25 years after the closure of the study. 
 
8. Study Management 
8.1 Source documents and archiving 
All documents relating to the study will be kept by the investigator: the original informed consent 
form, source documents, copy of the CRF, copy of the accountability of products administered, copy 
of the WIRB (ethics committee) approval and correspondence with the sponsor. 
The investigator will authorize direct access to the source documents during monitoring. As required 
by Canadian law, documents will be kept by the investigator for at least 25 years after the closure of 
the study.

 
 
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9. References 
Haub MD1, Hubach KL, Al-Tamimi EK, Ornelas S, Seib PA. Different types of resistant starch elicit 
different glucose reponses in humans. J Nutr Metab. 2010;2010. pii: 230501. doi: 
10.1155/2010/230501. Epub 2010 Jan 5. 
Al-Tamimi, E.K., Seib, P.A., Snyder, B.S., and Haub, M.D. 2010. Consumption of cross-linked resistant 
starch (RS4XL) on glucose and insulin responses in humans. J. Nutr. Metab. 2010:Article ID 651063. 
J. A. Higgins, D. R. Higbee, W. T. Donahoo, I. L. Brown, M. L. Bell, and D. H. Bessesen, “Resistant starch 
consumption promotes lipid oxidation,” Nutrition & Metabolism, vol. 1, article 8, 2004. 
D. J. A. Jenkins, V. Vuksan, C. W. C. Kendall, et al., “Physiological effects of resistant starches on fecal 
bulk, short chain fatty acids, blood lipids and glycemic index,” Journal of the American College of 
Nutrition, vol. 17, no. 6, pp. 609–616, 1998. 
D. J. A. Jenkins and C. W. C. Kendall, “Resistant starches,” Current Opinion in Gastroenterology, vol. 
16, no. 2, pp. 178–183, 2000. 
P.-W. So,W.-S. Yu, Y.-T. Kuo, et al., “Impact of resistant starch on body fat patterning and central 
appetite regulation,” PLoS ONE, vol. 2, no. 12, article e1309, 2007. 
M. D. Robertson, A. S. Bickerton, A. L. Dennis, H. Vidal, and K. N. Frayn, “Insulin-sensitizing effects of 
dietary resistant starch and effects on skeletal muscle and adipose tissue metabolism,” American 
Journal of Clinical Nutrition, vol. 82, no. 3, pp. 559–567, 2005. 
D. L. Topping,M. Fukushima, and A. R. Bird, “Resistant starch as a prebiotic and synbiotic: state of the 
art,” Proceedings of the Nutrition Society, vol. 62, no. 1, pp. 171–176, 2003. 
Wolever TMS, Jenkins DJA. The use of the glycemic index in predicting the blood glucose response to 
mixed meals. Am J Clin Nutr 1986;43:167-72.  
Wolever TMS. Effect of blood sampling schedule and method calculating the area under the curve on 
validity and precision of glycaemic index values. Brit J Nutr 2004;91:295-300. 
J. Zhou, R. J. Martin, R. T. Tulley, et al., “Dietary resistant starch upregulates total GLP-1 and PYY in a 
sustained daylong manner through fermentation in rodents,” American Journal of Physiology, vol. 
295, no. 5, pp. E1160–E1166, 2008. 
 

 
 
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Appendix  1– Fibersym Nutritional Data 
 

 
 
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Appendix 2: Physical Comfort Questionnaire 
 
20 Victoria Street, 3rd Floor
Toronto ON Canada M5C 2N8 
Tel 416-861-0506 
www.gilabs.com 
SUBJECTIVE PHYSICAL 
COMFORT 
 
Subject Initials 
 
Subject
Number 
 
GIL #  
Test Meal _____________ Date: 
/
/
  Time _____ 
                     
 
 
 
(dd/mm/yyyy) 
 
Symptoms 
SEVERITY 
Comment 
Bloating 
 
 
Low  _______________________________________________  High  
 
 
Belching 
 
      Low  _______________________________________________  High 
 
Nausea 
 
      Low  _______________________________________________  High  
 
Diarrhea 
 
      Low  _______________________________________________  High  
 
Flatulence 
 
     Low  _______________________________________________  High 
 
 
Other 
(specify) 
_______ 
 
      Low  _______________________________________________  High 
 
 

 
 
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Appendix 3: Satiety Questionnaire