APLIKASI CHRONO- NUTRITION : PENGARUH FIBER JELLY TERHADAP RESPON GLUKOSA DARAH, KEKENYANGAN POST PRANDIAL, DAN WEIGH LOSS PADA WANITA OVERWEIGHT"
Phase: NA
Conditions: Overweight and Obese Adults
Sponsor: Surabaya State University

RESEARCH PROTOCOL 
 
 
 
 
 
 
 
 
 
Chrono-Nutrition Application: The Effect of Fiber Jelly on Blood Glucose 
Response, Postprandial Satiety, and Weight Loss in Overweight Women 
 
 
 
 
 
 
 
 
NCT NUMBER/ID: Not Assigned Yet 
Protocol ID: No.004/UN38.10/EC.KEPK/HK.01.0 
 
 
 
 
 
Document Date 21 January 2026 
 

INFORMED CONSENT FORM 
Title of the Study 
Chrono-Nutrition Application: The Effect of Fiber Jelly on Blood Glucose Response, 
Postprandial Satiety, and Weight Loss in Overweight Women 
 
Principal Investigator 
Noor Rohmah Mayasari, Ph.D 
Faculty of Sports Science and Health 
Universitas Negeri Surabaya 
 
Sponsor / Research Institution 
Universitas Negeri Surabaya, Indonesia 
 
Introduction 
You are being invited to participate in a research study. Before you decide whether or not to 
take part, it is important that you understand why the research is being conducted and what 
your participation will involve. Please take time to read the following information carefully. 
You may ask questions at any time. 
Your participation in this study is completely voluntary. 
 
Purpose of the Study 
The purpose of this clinical nutrition study is to evaluate the effects of a fiber jelly product 
on: 
• 
Blood glucose response 
• 
Postprandial satiety (feeling of fullness after eating) 
• 
Weight loss outcomes 
in overweight adult women, within a chrono-nutrition framework. 
 
Study Product 
The study product is a fiber jelly made from basil seeds (Ocimum basilicum) and roselle 
calyces (Hibiscus sabdariffa). It is a functional food with a high dietary fiber content, 
designed as a healthy snack to support appetite control and blood glucose regulation. 
 

Study Procedures 
If you agree to participate, you will be asked to: 
1. Undergo screening assessments, including: 
o 
Measurement of body weight, height, and body fat composition 
o 
Blood glucose measurement 
o 
Blood pressure measurement 
o 
Review of medical history 
2. Fast overnight starting from 10:00 p.m. before the study day (only water is allowed). 
3. Attend the study visit at 08:00 a.m. at the Faculty of Sports Science and Health. 
4. Consume the fiber jelly product as instructed. 
5. Undergo finger-prick blood sampling to measure blood glucose levels at minutes 
0, 30, 60, 90, and 120. 
6. Complete Visual Analogue Scale (VAS) questionnaires to assess satiety at the same time 
points. 
7. Two hours after consuming the fiber jelly, eat until comfortably full and complete 
additional VAS questionnaires at minutes 180 and 240. 
Blood sampling will be performed by trained personnel using sterile equipment. 
 
Duration of Participation 
Your participation in this study will last approximately 2 weeks, with 2 point (2 days) data 
collection. 
 
Possible Risks and Discomforts 
The risks associated with this study are minimal and may include: 
• Mild pain, redness, or discomfort at the fingertip during blood sampling 
• Digestive discomfort such as bloating or gastric irritation after consuming fiber jelly 
• Rare allergic reactions 
All procedures will be conducted following strict hygiene and safety standards. If you 
experience any adverse effects related to the study, appropriate care will be provided by the 
research team. 
 
Benefits 
You may receive the following benefits: 
• Free blood glucose examination 

• Free dietary intervention 
• Incentives (e.g., e-money) as appreciation for your participation 
There may be no direct personal benefit. However, the information gained from this study 
may help improve nutritional interventions in the future. 
 
Alternatives to Participation 
You are free to choose not to participate in this study. Refusal to participate will involve no 
penalty or loss of benefits. 
 
Confidentiality 
All information collected during this study will be kept confidential. Your data will be 
identified by a study code rather than your name. Research results may be published, but your 
identity will not be revealed. 
 
Compensation and Costs 
There will be no cost to you for participating in this study. All study-related expenses will be 
covered by the researchers. You will receive compensation as described above. 
 
Right to Withdraw 
You may withdraw from the study at any time without giving a reason and without any 
penalty or loss of benefits to which you are otherwise entitled. 
 
Ethical Approval 
This study has been reviewed and approved by: 
Health Research Ethics Committee 
Faculty of Medicine, Universitas Negeri Surabaya 
Phone: +62 813-3910-5470 
Email: fk@unesa.ac.id 
 
Questions or Concerns 
If you have any questions about this study, your rights as a participant, or if you experience 
any problems, you may contact: 

Principal Investigator 
Noor Rohmah Mayasari, Ph.D 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PARTICIPATION APPROVAL SHEET 
 
 
All these explanations have been submitted to me and all questions have been answered by 
researchers.  I understand that if I need an explanation, I can ask Noor Rohmah Mayasari as 
principal investigator.  
I confirm that: 
• 
I have read and understood the information above. 
• 
I have had the opportunity to ask questions and received satisfactory answers. 
• 
I understand that my participation is voluntary and that I may withdraw at any time 
without penalty. 
 
By signing below, I freely agree to participate in this research study. 
 
Participant’s Name: ______________________________ 
Signature: ____________________________________ 
Date: ________________________________________ 
Witness Name: _________________________________ 
Witness Signature: _____________________________ 
 
 
Researcher Information: 
Principal Investigator 
Noor Rohmah Mayasari, Ph.D 
Nutrition department, Faculty of Sports and Health Sciences, Universitas Negeri Surabaya 
Email: noormayasari@unesa.ac.id 
 
Co-Principal Investigator 
Fista Utami,  
Nutrition department, Faculty of Sports and Health Sciences, Universitas Negeri Surabaya 
Email: fistautami@unesa.ac.id 
 

 dr. Endang Sri Wahjuni, M.Kes 
Medical Department, Faculty of Medicine, Universitas Negeri Surabaya 
Email: endangwahjuni@unesa.ac.id