Conditions: Pre-Diabetes
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 12
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine whether changing the microbial composition in the colon can improve metabolism of sugar in people who are on the verge of developing diabetes (pre-diabetics). Study participants will undergo a fecal microbiota transplantation (FMT) using material from lean donors, as well as a series of tests prior to and after the transplant. The investigators will examine any changes in fecal bacterial composition associated with FMT and determine if any observed changes have an influence on blood sugar metabolism.

Detailed description:

Arms:
arm 1: One week prior to FMT, a course of three oral antibiotics are taken: Vancomycin 500mg, Neomycin 1000mg, and Clindamycin 300mg. arm 2: One week prior to FMT, a course of three sugar pills identical to each antibiotic.

Interventions: intervention 1: Vancomycin intervention 2: Placebo intervention 3: Neomycin intervention 4: Clindamycin intervention 5: Fecal Microbiota Transplantation
Intervention descriptions: intervention 1: Vancomycin 3 times a day for 7 days intervention 2: Placebo pills identical in appearance to each antibiotics to be taken on the same schedule as each antibiotic intervention 3: Neomycin 3 times a day for 1 day intervention 4: Clindamycin 3 times a day for 5 days intervention 5: FMT conducted via colonoscopy

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
Interventional Bioremediation of Microbiota In Metabolic Syndrome 
 
 
 
Sponsor Investigator: Alexander Khoruts, MD 
Medical Biosciences Building 
Room 3-184 
2101 6th Street SE 
Minneapolis, MN 55414 
612.625.8999 
khoru001@umn.edu 
 
Study Product: 
 
Fecal Microbiota (FM) 
 
Protocol Number: 
CTSI# 22791 
 
IND Number: 
 
16346 
 
Trial Registration: 
NCT02730962 
 
Version / Date: 
 
Version 4 /19 May 2016 
 
 
 
 
 
 
 
 
CONFIDENTIAL 
 
This document is confidential and the property of the University of Minnesota.  No part of it may be transmitted, 
reproduced, published, or used by other persons without prior written authorization from the study sponsor-investigator. 
 
 
 
 


 
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Version 4.0 
   
Version History 
 
Version # 
Version Date 
Significant Changes from Previous Version 
Version 1 
09 Jan 2015 
Original Protocol Version 
Version 2 
09 Jun 2015 
Added secondary hypothesis and objective to test 
antibiotic conditioning versus placebo. Added two 
exclusion criteria regarding renal insufficiency and 
immune deficiencies.  
Version 3 
01 February 
2016 
Added procedures for lean donor group. Clarified 
dietary measures. Added procedures for oral glucose 
tolerance testing, resting metabolic rate, optional 6 
hour clamp, FitBit data, and tools for participants to 
record adverse events. Expanded table of contents to 
include sub-section headings. 
Version 4 
04 May 2016 
Increased number of participant visits from 13 to 15 
to account for time needed between body 
composition and insulin clamp assessments. 
Specified that hepatic MRI and fMRI will be 
optional procedures. Clarified stool sample 
collection procedures.  Added safety monitoring 
details. 
 
 
 
 
 
 


 
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Table of Contents 
1. 
Background Information and Scientific Rationale .................................................................9 
1.1. 
Hypotheses ..................................................................................................................9 
1.2. 
Background .................................................................................................................9 
1.3. 
Scientific Rationale ...................................................................................................13 
1.4. 
Potential Risks and Benefits .....................................................................................14 
1.4.1. Potential Risks ..............................................................................................15 
1.4.2. Known Potential Benefits .............................................................................16 
1.4.3. Risk/Benefit Ratio .........................................................................................17 
2. 
STUDY OBJECTIVES .........................................................................................................17 
2.1. 
Primary Objective .....................................................................................................17 
2.2. 
Secondary Objectives ................................................................................................17 
2.3. 
Exploratory Objectives .............................................................................................17 
3. 
STUDY DESIGN..................................................................................................................17 
3.1. 
Study Outcome Measures .........................................................................................18 
3.1.1. Primary Outcome Measures ..........................................................................18 
3.1.2. Secondary Outcome Measures ......................................................................18 
3.1.3. Exploratory Outcome Measures ...................................................................18 
4. 
STUDY ENROLLMENT AND WITHDRAWAL ..............................................................18 
4.1. 
Inclusion Criteria ......................................................................................................19 
4.2. 
Exclusion Criteria .....................................................................................................19 
4.3. 
Treatment Assignment Procedures ...........................................................................20 
4.3.1. Randomization Procedures ...........................................................................20 
4.3.2. Un-Blinding Procedures................................................................................20 
4.4. 
Withdrawal ................................................................................................................21 
4.4.1. Reasons for Withdrawal ................................................................................21 
4.4.2. Handling of Withdrawal ...............................................................................21 
4.5. 
Termination of the Study ..........................................................................................21 
5. 
INVESTIGATIONAL AGENTS..........................................................................................21 
5.1. 
Antibiotics/Placebo ...................................................................................................21 
5.2. 
FMT ..........................................................................................................................22 
5.3. 
Administration ..........................................................................................................22 
5.4. 
Maintaining Blind for Investigational Agent ............................................................23 
5.5. 
Accountability/Final Disposition for the Investigational Agent ...............................23 
5.6. 
Ancillary Supplies Description .................................................................................23 
6. 
STUDY PROCEDURES / EVALUATION SCHEDULE ...................................................23 
6.1. 
Clinical/Laboratory Evaluations and Study Schedule ..............................................23 
6.2. 
Initial Screening Visit (Day -40) ...............................................................................23 
6.3. 
Visit 1 - Baseline (Day -31, +/- 5 days) ....................................................................24 
6.4. 
Visit 2 (Day -25, +/- 5 days) .....................................................................................24 
6.5. 
Visit 3 (Day -18, +/- 5 days) .....................................................................................24 


 
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6.6. 
Visit 4 (Day -14, +/- 2 days) .....................................................................................25 
6.7. 
Visit 5 (Day -7, +/- 4 days) .......................................................................................25 
6.8. 
Colonoscopy Prep .....................................................................................................26 
6.9. 
Visit 6 (Day 0) – FMT ..............................................................................................26 
6.10. Visit 7 (Day 2, Phone/Home Visit) ...........................................................................26 
6.11. Visit 8 (Day 9, +/- 1 Day; ~ 1 week post FMT) .......................................................26 
6.12. Visit 9 (Day 16, +/- 2 Days, Phone/Home Visit; ~ 2 weeks post FMT) ...................26 
6.13. Visit 10 (Day 23, +/- 2 days, Phone/Home Visit) .....................................................27 
6.14. Visit 11 (Day 30, +/- 2 Days; ~ 4 weeks post FMT) ................................................27 
6.15. Visit 12 (Day 34, +/- 5 Days) ...................................................................................27 
6.16. Visit 13 (Day 41, +/- 5 Days) ...................................................................................27 
6.17. Visit 14 (Day 45, +/- 1 Week) or Early Termination ................................................28 
6.18. Visit 15 (Day 180 +/-1 Week) Safety Follow-Up .....................................................28 
6.19. Unscheduled Visits ...................................................................................................28 
6.20. Lean Donor Clinical/Laboratory Evaluations ...........................................................29 
6.21. Specimen Preparation, Handling, and Storage for Metabolomics ............................29 
6.22. Modified 2-Hour Oral Glucose Tolerance Test (MOGTT) ......................................30 
6.23. 6-Hour Hyperinsulinemic-Euglycemic Clamp .........................................................30 
6.24. Insulin Sensitivity Assessment with 3-Hour Hyperinsulinemic-Euglycemic Clamp31 
6.25. Dietary Follow-up .....................................................................................................31 
6.26. Resting Metabolic Rate Assessment .........................................................................32 
6.27. Fitbit Data Collection ................................................................................................32 
6.28. Hepatic Magnetic Resonance Imaging .....................................................................32 
6.29. Functional Magnetic Resonance Imaging .................................................................32 
6.30. iDXA Dual X-ray Absortiometry .............................................................................32 
6.31. Subject Compensation ..............................................................................................33 
7. 
SAFETY AND ADVERSE EVENTS ..................................................................................33 
7.1. 
Definitions.................................................................................................................33 
7.2. 
Recording of Adverse Events ...................................................................................35 
7.3. 
Reporting of Serious Adverse Events .......................................................................36 
7.3.1. IRB Notification by Sponsor-Investigator ....................................................36 
7.3.2. FDA Notification by Sponsor-Investigator ...................................................36 
7.3.3. UPIRTSO Events ..........................................................................................37 
8. 
CLINICAL MANAGEMENT OF EVENTS........................................................................37 
8.1. 
Adverse Event Management .....................................................................................37 
8.2. 
Temporary Interruption of Study Product in an Individual Subject .........................37 
9. 
CLINICAL SITE MONITORING PLAN ............................................................................37 
10. STATISTICAL CONSIDERATIONS..................................................................................37 
10.1. Study Hypotheses......................................................................................................37 
10.2. Sample Size Considerations ......................................................................................37 
10.3. Randomization ..........................................................................................................38 


 
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10.4. Blinding.....................................................................................................................38 
10.5. Planned Interim Analyses .........................................................................................39 
10.6. Safety Review ...........................................................................................................39 
10.7. Final Analysis Plan ...................................................................................................39 
11. DATA HANDLING / RECORD KEEPING / SOURCE DOCUMENTS ...........................39 
11.1. Data Capture Methods ..............................................................................................39 
11.2. Types of Data ............................................................................................................40 
11.3. Study Records Retention ...........................................................................................40 
11.4. Source Documents ....................................................................................................40 
11.5. Protocol Deviations ...................................................................................................40 
12. QUALITY CONTROL AND QUALITY ASSURANCE ....................................................40 
13. ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................................40 
13.1. Ethical Standard ........................................................................................................40 
13.2. Institutional Review Board .......................................................................................41 
14. INFORMED CONSENT PROCESS ....................................................................................41 
14.1. Subject Confidentiality .............................................................................................41 
14.2. Principal Investigator Responsibility When Subject Withdraws or is Discontinued41 
14.3. Future Use of Stored Specimens ...............................................................................41 
15. PUBLICATION POLICY ....................................................................................................42 
16. LITERATURE REFERENCES ............................................................................................43 
17. Appendix 1: Schedule of Events ...........................................................................................46 
18. Appendix 2:  Diet History Questionnaire II ..........................................................................49 
 
 
 


 
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List of Abbreviations 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase 
AST 
Aspartate Aminotransferase 
BMI 
Body Mass Index 
CDI 
Clostridium difficile Infection 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
DHQ 
Diet History Questionnaire 
DNA 
Deoxyribonucleic Acid 
ET 
Early Termination 
FDA 
Food and Drug Administration 
FFM 
Fat Free Mass 
FMT 
Fecal Microbiota Transplant 
FWA 
Federal-wide Assurance 
GIR 
Glucose Infusion Rate 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
IBD 
Inflammatory Bowel Diseases 
IBS 
Irritable Bowel Syndrome 
ICH 
International Conference on Harmonization 
ICMJE 
International Committee of Medical Journal Editors 
IDS 
Investigational Drug Service 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
ITT 
Intent to Treat 
MOGTT 
Modified Oral Glucose Tolerance Test 
NCI 
National Cancer Institute 
NDSR 
Nutrient Data System for Research 
PEG 
Polyethylene Glycol 
PICRUSt 
Phylogenetic Investigation of Communities by Reconstruction of        
Unobserved States 
PO 
Per Os (by mouth) 
RMR 
Resting Metabolic Rate 
SAE 
Serious Adverse Event 
UPIRTSO 
Unanticipated Problems Involving Risks to Subjects or Others 
TID 
Ter in Die (three times a day) 
US 
United States 


 
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Protocol Summary 
 
 
Title: 
Interventional Bioremediation of Microbiota In Metabolic 
Syndrome 
 
Phase: 
1 
 
Population: 
20 pre-diabetic, obese or overweight males and females.  
Subjects will be recruited from the Twin Cities metropolitan 
area and will participate as outpatients in this clinical study. 
 
Number of Sites: 
1 (University of Minnesota) 
 
 
Study Duration: 
 
48 months 
 
 
Subject Participation 
Duration: 
 
Approximately 8 months 
 
Agent or Intervention: 
 
Distal gut microbiota prepared from fecal material by filtration 
and frozen.  Subjects are randomized to antibiotic conditioning 
or placebo prior to receiving lean donor microbiota in a fecal 
microbiota transplantation procedure. 
 
Objectives: 
The primary objective of this study is to measure changes in 
insulin sensitivity using the insulin clamp technique associated 
with FMT in pre-diabetic subjects. 
 
Endpoints:                   
 
The primary endpoint is the change in insulin sensitivity 
measured by standard euglycemic insulin clamp.  Comparison 
will be made between the baseline measurement ~ 4 weeks 
prior to FMT and final measurement ~ 6 weeks post-FMT. 
 
 


 
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SCHEMA           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total N: 20
Consent 
Assess 
Eligibility 
Randomize 
Arm 2 
Placebo 
Arm 1 
Antibiotics 
Perform laboratory tests and other assays 
Administer lean donor microbiota in FMT 
Clinical and Adverse Event Assessment 
Assessment of Final 
Outcome Measures 


 
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1. Background Information and Scientific Rationale 
 
1.1. Hypotheses 
 
Primary Hypothesis: We propose that replacement of dysfunctional or disrupted (dysbiotic) 
microbiota in overweight or obese pre-diabetic subjects with microbiota obtained from lean 
donors will lead to greater improvement in insulin sensitivity.  Furthermore, we anticipate that 
lean microbiota engraftment will result in a change in dietary intake and functional brain 
imaging will demonstrate altered responsiveness toward calorie-rich food images in homeostatic 
and hedonistic areas of the brain.  
   
Secondary Hypothesis: We anticipate that optimal engraftment of the donor microbial 
community will require an antibiotic conditioning regimen.  Thus, half of our subjects will be 
treated with antibiotics prior to FMT, and the other half will receive placebo.  All subjects will 
undergo FMT using lean donor microbiota.  We will measure similarity of recipient microbiota 
to donor in terms of taxonomic phylotypes and functional (metabolic) potential.  
 
1.2. Background 
Metabolic syndrome is a chronic disorder of energy utilization and storage in humans.  Its 
multiple complications including obesity, diabetes, vascular disease, osteoarthritis, sleep apnea, 
liver disease, increased cancer risk, and many others, constitute the largest single health 
problem in the US and increasingly the world.  A core problem underlying obesity and diabetes 
is the imbalance between energy intake/harvest and expenditure/distribution, which has 
simplistically been viewed as a mere issue of diet and exercise.   Weight-loss programs based 
on diet and exercise alone typically achieve only short-term improvements, and typically fail to 
reach their target goals despite considerable investment of effort and resources.  The failure is 
often blamed on the patient, but likely results from other factors that remain poorly understood 
in this complex disease.   
 
While genetic predisposition plays a role in individual susceptibility to metabolic syndrome, 
environmental factors are undoubtedly involved since the pace of the obesity epidemic over the 
past several decades cannot possibly be explained by genetic selection.  Recently, a number of 
seminal studies, done in both animals and humans, recognized the important role of gut 
microbiota in whole-body energy metabolism, and a compelling case now exists that altered gut 
microbiota is one of the elusive environmental influences driving the ongoing obesity epidemic 
(Cox and Blaser, 2013; Musso et al., 2011; Tremaroli and Backhed, 2012; Turnbaugh and 
Gordon, 2009). The composition and metabolic potential of gut microbiota in obese individuals 
is characteristically different from that in lean individuals.  Specifically, microbiota from obese 
individuals contains less taxonomic diversity and is deficient in its potential to digest complex 
polysaccharides (Ridaura et al., 2013; Shen et al., 2013).  In a landmark study of twins 
discordant for obesity, microbiota from obese siblings induced weight gain in germ-free animals 
irrespective of recipient diet composition (Ridaura et al., 2013).  In contrast, microbiota from 
lean siblings inhibited this weight gain, but only on a diet rich in complex polysaccharides (i.e. 
high in whole grains, fruits, and vegetables).  This result may explain why diet alone typically 
fails in individuals lacking the appropriate gut microbiota.  
 
 


 
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The human body represents a complex synergistic platform for microorganisms, which have co-
evolved with their host and exist in highly organized and specialized microbial communities.  
The gastrointestinal tract contains 99% of these microbes, with numbers approaching 1011/mg in 
the luminal contents of the colon. Collectively, these microbes outnumber the number of host 
cells by a factor of ten to one, and contain >100-fold more genes.   Scientifically, the gut 
microbiota is now recognized as an organ integral to human physiology, and interacts intimately 
with the host metabolism and the immune system (Backhed et al., 2005).  Since the vast 
majority of commensal gut microorganisms cannot be cultured in vitro using classical 
microbiological techniques, the entire field of host-microbiota interactions could not develop 
until emergence of culture-independent technologies that use metagenomics, 
metatranscriptomics, metabolomics (and other ‘omics’) technologies armed with computational 
methods able to analyze massive amounts of data.  Over the last several years major initiatives, 
such as the NIH-sponsored Human Microbiome Project (HMP), started to define the “normal” 
bacterial constituents of the gut microbiome (HMP normal = healthy 18-40 year old individuals 
in several large American cities).  Strikingly, when compared to certain ancestral populations, 
such as those from rural communities in Malawi (Africa) and remote villages of Amerindians in 
the Amazon forest, the Western gut microbiome (even the lean individuals from the HMP 
database) is substantially less diverse (Yatsunenko et al., 2012).  Indeed, there has been 
increasing concern that changes in societal lifestyles, including pervasive use of antibiotics and 
increased consumption of calorie-rich processed foods, has resulted in population-wide 
ecological disruptions within our own bodies (Blaser, 2006).  A common theme in comparing 
Western siblings discordant for obesity or comparing Western versus ancestral community 
microbiome is the decreased potential to digest complex polysaccharides.  At first glance, this is 
counterintuitive since loss of digestive capacity should result in decreased energy harvest.  
However, microbial metabolites have the potential for extensive signaling within the host, and 
impact appetite, intestinal motility, metabolic rate, and energy storage.  
 
 
Over the recent years short chain fatty acids (SCFAs), the principal end-product of bacterial 
fermentation of polysaccharides (and include Formic acid, Acetic acid, Propionic acid, 
Isobutyric acid, Butyric acid, Isovaleric acid, and Pentanoic acid), have received the most 
attention as potential microbial products that can regulate host metabolism over the last several 
years.  They signal via the G-protein coupled free fatty acid receptors (FFARs), which are 
expressed widely in humans, including in the enteroendocrine system, liver, brain, sympathetic 
nervous system, muscle, adipose tissue, immune cells, and pancreatic beta cells (Fig 1).   
 
 
SCFAs promote intestinal gluconeogenesis, in part, via a gut-brain neural circuit, which is 
sensed by the liver and leads to decreased circulating glucose by inhibiting liver 
gluconeogenesis (De Vadder et al., 2014).  Moreover, SCFAs improve gut barrier function by 
enhancing secretion of gut peptides by the colonic L cells and by providing energy to the 
colonocytes.  An improved gut barrier lowers the circulating endotoxin levels and the associated 
inflammatory state characteristic of metabolic syndrome.  In addition, SCFAs participate in gut 
peptide mediated appetite suppression, adipose tissue signaling (e.g., increased leptin 
production), and pancreatic -cell function (Shen et al., 2013).  However, it is also virtually 
certain that other products of microbial metabolism are involved in human energy metabolism.  
In fact, ~ 10% of circulating small molecules in the body are derived from microbial 
metabolism (Wikoff et al., 2009)!  Secondary bile acids, produced in the distal gut, are known 


 
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to be involved in host lipid metabolism and immune function (Stepanov et al., 2013).  Gut 
microbiota are also involved in setting the tone of the endocannabinoid system, which plays an 
important role in food intake (Cani et al., 2007; Muccioli et al., 2010).  Collectively, there is 
compelling evidence that altered gut microbiota activity of individuals with metabolic syndrome 
can impact all aspects of energy metabolism: energy intake, harvest, expenditure, storage, and 
distribution.  Physiologically, insulin resistance and increased circulating levels of glucose, 
which ultimately manifest as type 2 diabetes, are one of the central features in metabolic 
syndrome.  
 
 
No serious study of human obesity and metabolic syndrome can ignore the central role of eating 
behavior, which is dictated both by metabolic requirements and multiple psychological, social, 
and environmental influences.  With the development of functional MRI (fMRI) technology, 
researchers have been able to visualize a network of brain areas that are activated in response to 
nutrient ingestion, food cues, anorexigenic and orexigenic gut peptides, and hormones such as 
insulin and leptin (De Silva et al., 2012).  Certain areas of the brain, such as the hypothalamus, 
regulate food intake based on homeostatic signals, e.g., glucose levels and hormone signaling, 
and are dependent on central insulin sensitivity.  However, several other regions, including the 
ventral and dorsal striatum, insula, anterior cingulated cortex, amygdala, orbitofronal cortex, 
ventral pallidum, and medial prefrontal cortex, incorporate hedonistic calculus into the overall 
food intake control. Collectively, multiple studies demonstrate that obesity is associated with 
both altered responsiveness in homeostatic brain regions, and altered responsiveness in the 
hedonistic regions characterized by hyperactive reward to high calorie food cues and reduced 
consummative food reward.  Furthermore, activity in both homeostatic and hedonistic brain 
centers is regulated in part by satiety-related gut hormones, which are modulated by products of 
microbial metabolism (Shen et al., 2013).   
 
 
Most of our current understanding in this highly complex field is built on association studies.  
While these studies have offered some insights, the next step towards making causal 
connections requires direct interventional approaches.  However, we are a long way from 
understanding rules of microbial community assembly and function within the human host.  
While probiotics may have some potential in altering the gut microbial community structure, 
microorganisms contained in probiotics are often limited in number, not adapted to the human 
host, do not become established (fail to engraft), and their effects are generally negligible, 
indirect, and unpredictable.   
 
Currently, the most effective known way to substantially alter the gut microbiota is to perform 
fecal microbiota transplantation (FMT).  A promising pilot study on FMT analogous to one we 
propose here was reported by Vrieze and colleagues in 2012 (Vrieze et al., 2012).  Male 
subjects with metabolic syndrome (9 per group) received their own fecal microbiota or fecal 
microbiota from lean male donors via a duodenal tube following bowel lavage.  The allogenic 
(non-self) treatment group was found to have increased fecal microbial diversity, increased 
prevalence of a butyrate-producing bacterium, Roseburia intestinalis, and increased peripheral 
insulin sensitivity 6 weeks after the procedure, while the autologous (self) treatment group 
experienced no changes.   


 
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Figure 1.  Microbiota, food, and brain function in the pathogenesis of insulin resistance 
and development of diabetes.  Metabolically capable microbiota, illustrated on the left side of 
the figure, digest complex polysaccharides reaching the distal gut and produce end products, 
such as short chain fatty acids, which strengthen the gut barrier function.  In contrast, less 
capable microbiota, illustrated on the right side of the figure, is not able to perform this function 
well, which leads to disrupted gut barrier function.  Microbiota in individuals with metabolic 
syndrome also contains higher proportion of Proteobacteria (Gram-negative facultative 
anaerobes), which tend to translocate more readily through the gut causing “metabolic 
endotoxemia”.  Short chain fatty acids have pleiotropic effects within the intestine and 
throughout the host, which is illustrated by various target organs such as liver, muscle, the 
immune system, and adipose tissue.  Butyrate and propionate promote intestinal 
gluconeogenesis, which leads to increased portal vein glucose concentration and decreased liver 
gluconeogenesis, which ultimately leads to lower systemic glucose levels.  Short chain fatty 
acids also promote secretion of satiety-related gut neuropeptides by the enterochromaffin cells, 
which alter the brain responsiveness to food stimuli.  All combined, optimized diet and 
microbiota are both necessary to achieve best insulin sensitivity and prevent or treat metabolic 
syndrome.  
    
 
Over the past number of years we have developed a clinical fecal microbiota transplant program 
for treatment of patients with refractory Clostridium difficile infection (CDI).  The vast majority 
of these patients have multiply recurrent C. difficile infection syndrome (R-CDI), a condition 
characterized by virtual certainty of infection relapse if anti-CDI antibiotics, e.g., vancomycin 
or fidaxomicin, are discontinued.  We and others have shown that fecal microbial community 
structure in these patients is markedly disrupted with marked decrease in overall microbial 


 
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diversity, commonly complete loss of the entire Bacteroidetes phylum, and major relative 
expansion of the Proteobacteria, and specifically members of the family Enterbacteraceae.  
FMT results in prompt recovery of normal (donor-like) fecal microbial community structure, 
which is associated with rapid resolution of this clinical syndrome.   
 
In our program we developed standardized protocols of rigorous donor screening and testing, 
consistent laboratory preparation of donor microbiota, and microbiota cryopreservation.  We 
will draw on this well-developed infrastructure to conduct this trial.  The most important 
difference, however, is that subjects entering this trial will not have had antibiotic-disrupted 
microbiota as our classical CDI patients.  Our CDI patients are offered FMT only after failure of 
all standard antibiotic regimens, which equals to a massive amount of antibiotic exposure in 
multiple cycles over an average period of a year (Hamilton et al., 2012).  Therefore, it is not 
surprising that we observe prompt restoration of the normal fecal microbial community 
structure that closely resembles the donor microbiota.   
 
In contrast to the experience with FMT in treating CDI, several groups have done pilot studies 
with FMT in treatment of ulcerative colitis.  Angelberger and colleagues used metronidazole for 
5-10 days prior to FMT, and saw evidence of stable engraftment only in one recipient 
(Angelberger et al., 2013).  Interestingly, this recipient also had the best clinical response.  
Engraftment was either transient or minimal in the other 4 subjects in the study.  Rossen and 
colleagues have recently reported results from a phase 2 trial of FMT, where one group received 
their own (autochthonous) microbiota, and the other group received healthy donor microbiota 
via nasoduodenal infusion (Rossen et al., 2015).  There was some evidence of engraftment in 
the recipients of allochthonous microbiota, although basic microbial community structure 
signatures were comparable in responders of both groups.  The clinical response rates were 
comparable between recipients of autochthonous and allochthonous microbiota.  The 
methodological differences in terms of recipient characteristics and microbiome analysis 
between the two studies make it impossible to comment on the value of metronidazole pre-
treatment.  However, a single antibiotic that has previously been found to have no beneficial 
effect in ulcerative colitis and targeting arguably the most desirable constituents of microbiota 
highlights the need for greater exploration of this point.    
 
Taking the results of these previous trials together, we hypothesize that an antibiotic 
conditioning regimen will be essential in this protocol to achieve optimal engraftment.  In order 
to test this hypothesis, half of the subjects in this study will be treated with a cocktail of 
antibiotics prior to FMT and the other half will be given placebo. 
 
1.3. Scientific Rationale 
Distal gut microbiota participate in all aspects of energy metabolism, including energy intake, 
harvest, distribution, and expenditure.  Products of microbial fermentation, such as SCFAs, 
have the potential to interact with multiple signaling pathways in the host.  Individuals who are 
obese or have diabetes have altered composition of distal gut microbiota.  Replacing this 
microbiota with that isolated from lean individuals has the potential to have beneficial effects on 
energy metabolism. 
 


 
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The goal in this study is to achieve an ecologically stable state of gut microbiota that is 
metabolically more capable to digest complex polysaccharides, produce short chain fatty acids, 
and less capable in breaching the gut barrier.  We hypothesize that in order to achieve that we 
will need to suppress the native microbiota and open up ecological niches in the intestine for 
optimal engraftment of new microbial constituents.   
 
 
The role of conditioning antibiotics prior to FMT has not been systematically investigated. We 
hypothesize that antibiotic conditioning is critical for successful engraftment of the donor 
microbial community.  We will now directly test how antibiotic conditioning contributes to 
donor microbiota engraftment – half of our subjects will receive antibiotics and half will receive 
placebo.  All subjects will undergo FMT using lean donor microbiota.  
 
 
1.4. Potential Risks and Benefits 
FMT has emerged in the recent years primarily as a response to the C. difficile epidemic.  
Multiple case series collected from across the US, Canada, Europe, Australia have been 
consistent in the overall efficacy of this procedure, regardless of technical details such as route 
of administration.  A small, randomized trial was reported in 2013 using FMT in the treatment 
of recurrent CDI, in comparison with standard antibiotic therapy.  Thus far, the experience has 
been impressive for clinical efficacy, and few reported side effects.  A multicenter experience 
reported by Kelly and colleagues on using FMT in 80 immunosuppressed patients suffering 
from recurrent CDI did not uncover infectious disease risks in this theoretically most vulnerable 
population.  However, we recognize the unknown elements of complex microbiota, even when 
prepared from absolutely asymptomatic, healthy donors.  We cannot exclude the possibility of a 
potential pathobiont, silent in the donor, causing an infection in the new recipient.  In addition, 
we cannot exclude a possibility that a particular microbial community may in result in some 
untoward metabolic or immunologic consequence in a new host, even though it was apparently 
working well in the original donor.  On the other hand, it should be emphasized that these 
microbiota preparations are derived from healthy human donors.  By definition, each microbial 
community was already tested for decades in at least one human subject (the donor).  This 
cannot be said of any synthetic microbial preparation.   
 
The choice of antibiotics proposed in this study was guided by known effects of chosen drugs, 
our experience with patients suffering from recurrent C. difficile infections, and the literature on 
microbiota differences in patients with obesity and diabetes.  The colon microbiota is dominated 
by obligate anaerobes, primarily members of two bacterial phyla – Bacteroidetes and 
Firmicutes.  Microbiota in obese individuals have greater fraction of genes contributed by 
Actinobacteria and Firmicutes, while microbiota from lean individuals is enriched for genes 
contributed by Bacteroidetes (Qin et al., 2012; Turnbaugh et al., 2009).  Proteobacteria are 
generally increased in proportion in microbiota of diabetics and constitute the dominant bacteria 
that can penetrate the gut barrier and enter the blood stream (Amar et al., 2011; Tilg and 
Moschen, 2014).  The antibiotics used in this study, clindamycin and vancomycin, target the 
majority of obligate gut anaerobes.  Two antibiotics that have distinct mechanisms of action are 
likely to cause greater disruptive effects on the native microbial communities.  Neomycin was 
chosen to target Gram-negative bacteria, members of the Proteobacteria phylum, which are 
likely to breach the gut barrier and may be pathogenic in metabolic syndrome by causing 
systemic endotoxemia.   


 
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1.4.1. Potential Risks 
Antibiotic Conditioning:  There are risks associated with antibiotic medications, 
including allergic reactions to the drugs and development of drug-resistant bacteria.  
Subjects with known allergies to antibiotics used in this trial will not be recruited into the 
study.  The risk of forcing emergence of drug resistance in the native microbiota of the 
subjects is purely theoretical and has not been clearly documented in the literature.  FMT 
further mitigates this theoretical risk because normal microbiota will likely outcompete 
microorganisms that express antibiotic resistance genes in absence of continued antibiotic 
pressure given associated metabolic costs.  Subjects may, however, develop transient 
non-C. difficile antibiotic-associated diarrhea.   
 
The risk of developing Clostridium difficile infection during the antibiotic treatment is 
essentially nil because vancomycin is one of the antibiotics.  Vancomycin is an approved 
treatment for Clostridium difficile.  Resistance to vancomycin has not yet been described 
in the literature and at most is extremely rare.  The subjects are further very unlikely to 
get Clostridium difficile infection after completing antibiotics because they will receive 
FMT, using lean microbiota.  This microbiota is routinely being used in treatment of 
multiply recurrent C. difficile infections in our program (> 250 patients treated since 
2008, ~ 98% success rate).  
 
Clindamycin is well absorbed systemically. The administration of it will be limited to 
only 5 days, and there will be a 2-day washout period prior to FMT.  This is the only 
antibiotic that is highly bioavailable following oral administration in our protocol, and 
may increase the risk of a vaginal fungal infection.  If this happens, we will evaluate the 
patient and treat in accordance with standard guidelines, e.g., oral fluconazole.  
Neomycin has poor oral bioavailability (~ 3%) and has been specifically approved for 
clinical use for suppression of bacteria in the bowel, e.g., preoperative bowel preparation 
(up to 12 grams 24 to 48 hours prior to surgery) and treatment of hepatic encephalopathy 
(4 grams daily in chronic use).  However, this drug has a black box warning regarding 
potential nephrotoxicity and ototoxicity.  Therefore, neomycin administration will be 
limited to one day only (2 days prior to the FMT).  In addition, renal insufficiency is an 
exclusion criterion (Creatinine ≤ 1.25 mg/dL). 
 
FMT: The risks of FMT are largely mitigated by extensive donor screening and testing 
described in IND 15071, which is cross-referenced for the purpose of material 
preparation. However, given the complexity of gut microbiota and many unknowns in 
microbiota-host interactions, some risks remain intrinsic to the procedure.    
1. Potential infectious risk.  Gut microbiota are generally non-pathogenic since their well-
being depends on the well-being of the host.  However, many enteric pathogens have 
originated in gut microbiota, including C. difficile.  Some hosts are asymptomatic carriers 
of such pathogens, necessitating formal testing.  Some pathogens causing chronic 
infections, e.g., hepatitis viruses, can be shed in the fecal material.  


 
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2. Metabolic risk.  The premise of this application is that gut microbiota participate in all 
aspects of energy metabolism.   All donors in our Program are lean.  Any single feature 
of metabolic syndrome (BMI, hypertension, abnormal lipid panel, abnormal fasting 
glucose, abnormal liver function tests) excludes donor candidates from participation.  
However, clinical donor indicators may not be perfectly predictive of metabolic potential 
of his or her microbiota, and it is possible that an opposite from desired effect could 
result from the intervention.    
3. Risk of gastrointestinal symptoms.  Gut microbiota constitute an integral part of the 
gastrointestinal tract.  They can potentially play a role in a variety of gastrointestinal 
disorders, including irritable bowel syndrome (IBS) and inflammatory bowel disease 
(IBD).  FMT can trigger exacerbations of existing IBD.  However, FMT has also been 
reported to be successful in treatment of both IBS and IBD.  A number of clinical trials 
are ongoing in testing the idea that FMT can be a treatment for IBD.  Patients with R-CDI 
and underlying IBD have clearly benefited from FMT in our own FMT program.  Trials 
are also anticipated for IBS in some institutions.  Nevertheless, at this time there is at 
least a small theoretical risk of FMT triggering a gastrointestinal disorder, whether 
inflammatory, motility, or sensory constitutes a small theoretical risk.  This risk is 
mitigated by ensuring that the donor has no gastrointestinal problems of any kind. 
Common side effects associated with FMT include: fever, abdominal cramping, diarrhea, 
constipation, nausea, and bloating. 
4. Risk of autoimmunity.  Gut microbiota play critical roles in the development of the 
immune system.  Their role in the function of a mature immune system is unknown.  
There is a theoretical risk that some form of immune disorder can be triggered by a new 
composition of gut microbiota in a recipient.  This theoretical risk is mitigated by 
ensuring that the donor has no immunologic problems, including allergic disorders, 
serological evidence of autoimmunity, or autoimmune disorders. 
5. Risk of colorectal cancer.  Gut microbiota may participate in pathogenesis of colon 
cancer, although the causal link between specific composition of microbiota and colon 
cancer development has not been demonstrated.  This theoretical risk is mitigating by 
ensuring that the donor has no first-degree relatives of gastrointestinal malignancy and 
that the donor has gone undergone screening for colorectal cancer according to current 
guidelines from the American Society of Gastrointestinal Endoscopy and the American 
Gastroenterological Association. 
6. Risk of colonoscopy.  The FMT will be done by colonoscopic route of administration.  
Colonoscopy is the most common screening procedure for colon polyps and cancer in the 
US.  It is a low risk procedure, although it does involve a small risk of allergic reaction to 
sedative medications, perforation, or bleeding.  
 
1.4.2. Known Potential Benefits 
Metabolic syndrome and obesity are very complex disorders.  We are not expecting this 
trial to result in a cure.  We hope it will constitute an important step toward 
understanding the mechanisms of these disorders and contributions of the gut microbiota 
to their pathophysiology.  The potential benefits, therefore, are primarily societal in terms 
of enhancing understanding and ultimately finding better ways to treat these disorders.  


 
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Some subjects may benefit indirectly from participating in the study. The subjects will 
undergo a colonoscopy, which has the potential to identify polyps or earlier diagnosis of 
colon cancer.   
 
1.4.3. Risk/Benefit Ratio 
Overall the risk of participating in this study is small.  The benefit is primarily societal.  
Direct health benefits to participants could result from findings at the colonoscopy, e.g., 
identification and removal of adenomatous polyps, and the possibility of metabolic 
benefit if the study hypothesis is correct.   
 
2.  
STUDY OBJECTIVES 
 
2.1. Primary Objective 
The primary objective of this study is to measure changes in insulin sensitivity, using the insulin 
clamp technique, associated with FMT in pre-diabetic subjects and whether those changes differ 
by antibiotic vs. placebo conditioning. 
 
2.2. Secondary Objectives 
1. 
Evaluate the safety, tolerability, and feasibility of colonoscopic FMT, including antibiotic 
or placebo conditioning, in pre-diabetic subjects. 
2. 
Determine whether antibiotic conditioning regimen prior to FMT increases engraftment 
of donor microbiota compared to placebo conditioning. 
 
2.3. Exploratory Objectives 
1. 
Evaluate fecal, plasma, and urine metabolomic profiles before and after FMT  
2. 
Evaluate effects of FMT on the activity of homeostatic and hedonistic brain centers using 
fMRI. 
3. 
Estimate whether FMT results in altered eating behavior using food frequency 
questionnaires and dietary recalls. 
4. 
Measure changes in circulating liver enzyme levels (AST, ALT, Alkaline Phosphatase) 
following FMT. 
 
3.  
STUDY DESIGN 
This is a randomized, double-blind, pilot study of prediabetic patients using colonoscopic FMT 
with the aim of improving insulin sensitivity in the active antibiotic treatment arm.  The patients 
will be randomized in 1:1 ratio to receive antibiotic conditioning or placebo prior to FMT. In the 
FMT procedure, both groups will receive microbiota prepared from lean donors (as described in 
our IND 15071). This is a double-blind study: neither the subject, nor the study physician 
administering the antibiotics, will know whether the subject received antibiotics or placebo. All 
subjects will have their luminal colon contents purged with a colonoscopy prep prior to FMT. 
 


 
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Subjects will be recruited at the University Academic Health Center, targeting outpatient 
endocrinology and liver disease outpatient clinics.   
 
3.1. Study Outcome Measures  
The subjects will be coming to clinic as described in the Schedule of Events Table in the 
Appendices.  
 
3.1.1. Primary Outcome Measures  
Primary outcome measures in this study include: 
1. Insulin sensitivity measured by standard euglycemic insulin clamp.  We will compare 
post-FMT insulin sensitivity measurements between subjects that received antibiotic 
versus placebo conditioning.  
2. Difference between the baseline measurement ~ 4 weeks prior to FMT and final 
measurement ~ 6 weeks post-FMT within each group (antibiotic and placebo 
conditioned). 
 
3.1.2. Secondary Outcome Measures  
Secondary outcome measures in this study include: 
1. Changes in fecal bacterial composition (pre- vs. post-FMT) associated with antibiotic 
vs. placebo conditioning, assessed by laboratory analysis. 
2. Changes in fecal bacterial composition associated with FMT overall (pooling 
antibiotic and placebo conditioning groups) by laboratory analysis. 
3. Adverse event rates overall and within antibiotic vs. placebo conditioning groups, 
assessed by review of adverse event diary card, specific questioning, and, as 
appropriate, examination. 
 
3.1.3. Exploratory Outcome Measures 
Exploratory outcome measures in this study include:  
1. Evaluate effects of FMT on the activity of homeostatic and hedonistic brain centers 
using fMRI. 
2. Change in liver fat content pre- vs. post-FMT using MRI.  
3. Change in total energy and macro- and micronutrient intake pre- vs. post-FMT using 
FFQs and 3-day diet records. 
4. Changes in resting metabolic rate and body composition pre- vs. post-FMT using 
indirect calorimetry. 
5. Changes in circulating liver enzyme levels (AST, ALT, alkaline phosphatase) pre- vs. 
post-FMT assessed by clinical laboratory analysis. 
 
4.  
STUDY ENROLLMENT AND WITHDRAWAL 


 
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4.1. Inclusion Criteria 
Subjects will be eligible to participate in the study if all of the following conditions exist: 
1. 
Provide informed consent 
2. 
Ambulatory and community dwelling 
3. 
Age 18 - 70 years of age 
4. 
Able and willing to comply with the study schedule and procedures 
5. 
Pre-diabetic with fasting blood glucose > 100 mg/dL and/or blood glucose 140-200 
mg/dL 2-hours after ingestion of 75 gm glucose and/or Hemoglobin A1C > 5.7-6.5 
percent 
 
4.2. Exclusion Criteria 
Subjects will be excluded from participation in the study if any of the following conditions exist: 
1. 
Serious, concomitant illness that, in the opinion of the Investigator, would interfere with 
evaluation of safety or efficacy, or put the subject at risk of harm from study 
participation.  
2. 
Known inflammatory bowel disease (Crohn’s disease, ulcerative colitis, lymphocytic 
colitis). 
3. 
Current abnormal liver tests that may be attributed to a cause other than non-alcoholic 
liver disease.  NOTE: These exclusionary conditions may include viral hepatitis, 
alcoholic liver disease, hemochromatosis, Wilson’s disease, medication-induced liver test 
abnormalities, celiac disease. 
4. 
Renal insufficiency, defined as creatinine ≤ 1.25 mg/dL  
5. 
Significant alcohol use, defined as > 20 g/day in females and > 30 g/day in males for a 
period of 3 months within one year prior to screening. 
6. 
Underlying chronic gastrointestinal disease that can cause diarrhea, including short bowel 
syndrome, diarrhea-predominant irritable bowel syndrome, malabsorption, celiac disease. 
7. 
History of partial or complete colectomy. 
8. 
History of malabsorptive bariatric surgery. 
9. 
Use of insulin or hypoglycemic medications.  
10. 
History of anaphylactic food allergies, e.g., peanuts, seafood. 
11. 
Food intolerances and allergies, including gluten sensitivity, lactose intolerance, and 
intolerance of high fiber dietary content. 
12. 
Symptomatic problems associated with intestinal gas and bloating. 
13. 
Irritable bowel syndrome, including diarrhea-dominant, constipation-dominant, and 
mixed. 
14. 
Functional GI disorder. 


 
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15. 
Unable to tolerate a colonoscopy. 
16. 
Presence of an indwelling intravenous line. 
17. 
Infection requiring antibiotics other than the conditioning antibiotics during the study 
period. 
18. 
Inability to take vancomycin, neomycin, and clindamycin antibiotics prior to FMT due to 
known hypersensitivity or intolerance. 
19. 
Major genetic immune dysfunction (e.g., common variable immune deficiency). 
20. 
Acquired immune deficiencies due to infections such as HIV. 
21. 
Immunosuppressive medications including one of the following: systemic corticosteroids, 
calcineurin inhibitors, thipurines, methotrexate, biologics (e.g., anti-tumor necrosis factor 
drugs), cancer chemotherapy. 
22. 
Planned use of oral probiotics while on study. 
23. 
Planned or ongoing chemotherapy for malignancy. 
24. 
Planned antibiotic therapy within the period of the study, e.g., perioperative antibiotics. 
25. 
Pregnant or lactating.  Female participants of child-bearing age and their partners will be 
counseled on contraceptive measures to prevent pregnancy during the study period.   
26. 
History of drug or alcohol abuse in the past 2 years. 
27. 
Currently participating in another clinical study. 
28. 
Legally incompetent and unable to understand the study’s purpose, significance and 
consequences, and to make decisions accordingly. 
29. 
Presence of metal implants, such as surgical clips or pacemakers, which will preclude 
performance of MRI tests. 
30. 
Inability to undergo MRI testing for any reason, e.g., claustrophobia. 
 
4.3.     Treatment Assignment Procedures 
This is a randomized, double-blind study.  Subjects are randomized in a 1:1 ratio to receive 
antibiotics or placebo prior to FMT with lean donor microbiota.  
 
4.3.1. Randomization Procedures 
Lean donor fecal microbiota suitable for FMT will be prepared from all study subjects in 
accordance with the laboratory protocols outlined in IND 15071.  The study statistician 
will prepare a randomization schedule.  Randomization of subjects will occur at the 
University of Minnesota Investigational Drug Service (IDS).  Randomly permuted 
blocks will be used for creating the randomization schedule. 
 
4.3.2. Un-Blinding Procedures  
In the unlikely event it becomes necessary to break the blind for an individual subject 
the treatment assignment for that subject only will be revealed.  A broken blind must be 
clearly justified and explained by a comment on the appropriate case report form (CRF). 


 
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4.4. Withdrawal 
4.4.1. Reasons for Withdrawal 
A study subject will be discontinued from further study agent/interventions in the study 
for: 
 Completion of the study; 
 Request by subject to terminate participation; 
 Requirement for prohibited concomitant medication or treatment; 
 Unable to comply with requirements of the protocol; 
 Lost to follow-up; 
 At the request of the institutional review board (IRB); 
 The subject’s well-being, based on the opinion of the investigator. 
 
Subjects who are discontinued from further study agent/interventions will be followed 
for safety until completion of the normal visit schedule.  Subjects will be contacted by 
phone within one week after the course of antibiotics ± FMT procedure, and again at one 
month and two months after the procedure. 
 
4.4.2. Handling of Withdrawal 
Subjects will be encouraged to complete the study; however, they may voluntarily 
withdraw at any time.  The sponsor-investigator will provide a written explanation of the 
reason for withdrawal in a source document and the reason will be recorded on a case 
report form.  Subjects will be asked for permission to continue scheduled evaluations, 
and complete an end-of-study evaluation. Medical care that may be required for 
management of adverse events in the course of the study will be charged to the medical 
insurance of the participant.  Subjects who drop out of the study will not be replaced. 
 
4.5. Termination of the Study 
If the sponsor-investigator or appropriate regulatory officials discover conditions arising during 
the study that indicate that the study should be halted, this action may be taken after appropriate 
consultation between the  sponsor-investigator, study statistician, and independent medical 
monitor. Conditions that may warrant termination of the study include, but are not limited to, 
the following: 
 The discovery of an unexpected, serious, or unacceptable risk to the subjects 
enrolled in the study, 
 
A decision on the part of the sponsor-investigator to suspend or discontinue testing, 
evaluation, or development of the product. 
 
5.  
INVESTIGATIONAL AGENTS 
 
5.1. Antibiotics/Placebo  
Subjects will be randomized 1:1 to receiving antibiotics or placebo prior to FMT. The 
antibiotics will be purchased commercially by the University of Minnesota’s Investigational 


 
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Drug Service (IDS). IDS will prepare the placebo to be identical in appearance to the three 
antibiotics. 
 
Subjects assigned to the antibiotic group will receive the following three antibiotics: 
 
 Vancomycin 500 mg PO TID for 7 days,  
 
 Neomycin 1000 mg PO TID for 1 day, and  
 
 Clindamycin 300 mg PO TID for 5 days 
 
5.2. FMT 
Single donor lots of minimally manipulated microbial material derived from feces of qualified 
lean donors will be prepared as described in IND 15071.  Product is intended for homologous 
function and localized use as replacement of missing components to restore normal microbial 
ecology and function of the distal gut.  Lean donor eligibility qualifications are identical to 
those described in IND 15071.  The fecal microbiota product will be formulated, packaged, and 
labeled as described in IND 15071.  Only frozen product will be used.  It will be stored as 
described in IND 15071.  The cryobags will be thawed in a 4 ± 2oC ice bath over 15 minutes 
and they may remain in the ice bath for up to 3 hours prior to administration into study subjects.  
 
5.3. Administration 
 
Antibiotics/Placebo: 
The antibiotics/placebo will be dispensed by IDS in a blinded fashion and administered by the 
study investigator.  
 
FMT: 
The fecal microbiota will be administered via colonoscopy as described in IND 15071. The 
fecal material suspension will be injected, via colonoscopy, into the terminal ileum and/or 
cecum.  Following the FMT, subjects will remain supine for 30 minutes and vital signs will be 
measured per colonoscopy recovery routine.  
 
The rationale for choosing colonoscopic route of administration includes: 
 Our program has the greatest experience with this route of administration, including 
data on microbiota engraftment in patients treated for recurrent CDI. 
 Some of the conditions discovered by colonoscopy constitute important metadata, i.e., 
covariant data important in the compositional microbiota analysis, which is one of the 
primary endpoints in our study.  For example, presence or absence of diverticulosis 
may affect composition of microbiota in the new host. 


 
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 Colonoscopy ensures that the patient has purged the colon of all residual luminal 
contents, which presumably may include antibiotics that can affect implantation of 
fecal microorganisms. 
 Some of the conditions discovered by colonoscopy may be exclusion criteria in this 
study, e.g., inflammatory bowel disease. 
 
5.4. Maintaining Blind for Investigational Agent 
The sponsor-investigator will not have access to the antibiotic or placebo during their 
preparation at the IDS.  
 
5.5. Accountability/Final Disposition for the Investigational Agent 
Molecular and Cellular Therapeutics, the manufacturer, will maintain product records for the 
manufacturing process through delivery of the product to the sponsor-investigator.  The 
Molecular and Cellular Therapeutics facility will maintain product accountability records 
from receipt through dispensing the product to the sponsor-investigator. The sponsor-
investigator will record administration of the product to each subject. 
 
5.6.    Ancillary Supplies Description  
The following ancillary supplies are for the FMT procedure. As part of the standard colon 
cleansing preparation, MoviPrep (PEG-based purgative for colonoscopy or another FDA-
colonoscopic preparation in case the subject is intolerant of MoviPrep) will be dispensed by 
IDS and administered by the study investigator to the subject.  Sedative medications will be 
administered by the study investigator for standard colonoscopy prep and procedure. 
 
 
6.  
STUDY PROCEDURES / EVALUATION SCHEDULE 
 
6.1. Clinical/Laboratory Evaluations and Study Schedule  
Consent will be obtained before any clinical evaluations are performed.  There is one screening 
visit and 15 visits planned over the approximately 8 month study duration for each subject.  The 
study will last until every evaluable subject has completed the Safety Follow-Up Visit. (See 
Schedule of Events in the Appendices). 
 
6.2.   Initial Screening Visit (Day -40) 
The study will be explained to potential subjects qualified from initial recruitment referrals.  
Consent will be obtained at this time that will go over all the procedures and studies involved. 
During this visit the medical history will be collected and inclusion/exclusion criteria will be 
thoroughly reviewed. The following procedures will occur after the consent form is signed: 
 
 Medical history, including medications over the previous 12 months, and demographics 
 Thorough review of the study, including involved procedures 
 Review of methods used to record and measure food consumption during the study, to 
be conducted by dietitian. 


 
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 Three-day diet record is initiated following this visit, to be completed prior to visit 1 
(baseline).  
 Complete physical examination  
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Height and weight 
 Measurement of serum creatinine, unless a recent (< 1 month) result is available 
 Possible repeat of fasting glucose, HgbA1C, or hepatic panel testing if recent (< 6 
months) results are not available 
  
 
6.3. Visit 1 - Baseline (Day -31, +/- 5 days) 
The following procedures are conducted during this visit.   
 Fasting blood collection for research measurements including metabolomics and flow 
cytometry 
 Modified 2-hour oral glucose tolerance test 
 Urine collection for metabolomics 
 Urine pregnancy test for women of childbearing potential 
 Feces collected for research measurements, including microbial and metabolomics 
composition 
 Dietitian assessment to review 3-day diet record, with directions to repeat prior to Visit 
4 
 NCI Diet History Questionnaire II (DHQ II) to assess the baseline diet of subjects prior 
to entry into the study 
 Subjects receive Fitbit and instructions on use 
 Subjects receive adverse events diary card and instructions on completion 
 Subjects receive thermometer 
 Clinical labs including liver function tests, fasting lipid panel, CRP level 
 Adverse events 
 Concomitant medications 
 
 
6.4. Visit 2 (Day -25, +/- 5 days) 
 Fecal and urine samples are collected 
 Urine pregnancy test for women of childbearing potential 
 Weight 
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 fMRI (optional) 
 Hepatic MRI (optional) 
 iDXA 
 Download Fitbit data 
 Adverse events 
 Concomitant medications 
 
6.5. Visit 3 (Day -18, +/- 5 days)  


 
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 Fecal and urine samples are collected 
 Clinical labs including hepatic panel, fasting lipid panel, CRP level, blood glucose 
 Urine pregnancy test for women of childbearing potential 
 Weight 
 Resting metabolic rate assessment 
 6-hour insulin clamp (option for 3-hour clamp if participant does not consent for 6-hour 
procedure) 
 Clinical labs 
 Download Fitbit data 
 Adverse events 
 Concomitant medications 
 
 
6.6. Visit 4 (Day -14, +/- 2 days) 
The following procedures are conducted during this visit.   
 Weight 
 Dietitian visit to review 3-day diet record, with directions to repeat prior to Visit 5. 
 Download Fitbit data 
 Urine pregnancy test for women of childbearing potential 
 Randomly assigned treatment (either antibiotics or placebo) are dispensed to the subject 
to take home.   The antibiotic regimen is described in the following list. There is a two 
day washout of neomycin and clindamycin before FMT. 
o vancomycin 500 mg PO three times daily x 7 days (Day -8 – Day -2),  
o neomycin 1000 mg PO three times daily x 1 day (Day -2), 
o clindamycin 300 mg PO three times daily x 5 days (Day -8 to Day -3).  
 Adverse events 
 Concomitant medications 
 
6.7. Visit 5 (Day -7, +/- 4 days) 
The following procedures are conducted during this visit.   
 Brief physical examination   
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Weight 
 Dietitian visit to review 3-day diet record, with directions to repeat at least 24 hours 
prior to visit 6.  
 Colonoscopy prep instructions are reviewed and prep supplies are picked up. NOTE: 
Colonoscopy prep supplies will be dispensed by the study coordinator. 
 Urine pregnancy test for women of childbearing potential 
 Fasting blood collection for metabolomics and flow cytometry 
 Fecal and urine samples are collected 
 Download Fitbit data 
 Adverse events 
 Concomitant medications 
 


 
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6.8. Colonoscopy Prep 
Preparation for colonoscopy is done on Day -1, the day before the FMT procedure. This is not a 
study visit. 
 
6.9. Visit 6 (Day 0) – FMT 
The following procedures are conducted during this visit.   
 Urine pregnancy test for women of childbearing potential 
 Clinical labs including hepatic panel, fasting lipid panel, CRP level, blood glucose 
 Three-day diet record results from previous week submitted to dietitian, with 
instructions to repeat between visits 7 and 8. 
 Colonoscopy  
 Fecal microbiota transplant 
 Adverse events 
 Concomitant medications 
 
6.10. 
Visit 7 (Day 2, Phone/Home Visit) 
 Urine collection for metabolomics 
 Fecal sample collected for research  measurements, including microbial and 
metabolomic composition 
 Adverse events 
 Concomitant medications 
 
6.11. 
Visit 8 (Day 9, +/- 1 Day; ~ 1 week post FMT) 
The following procedures are conducted during this visit.   
 Brief physical examination 
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Weight 
 Fasting blood collection for metabolomics and flow cytometry 
 Clinical labs including hepatic panel, fasting lipid panel, CRP level, blood glucose 
 Urine collection for metabolomics 
 Fecal sample collected for research measurements, including microbial and metabolomic 
composition 
 Dietitian visit to review 3-day diet record, with directions to repeat prior to visit 9. 
 Download Fitbit data 
 Adverse events  
 Concomitant medications 
 
6.12. 
Visit 9 (Day 16, +/- 2 Days, Phone/Home Visit; ~ 2 weeks post FMT) 
 Urine collection for metabolomics 
 Fecal sample collected for research  measurements, including microbial and 
metabolomic composition 
 Dietitian to review 3-day diet record, with directions to repeat prior to visit 10. 
 Adverse eventsConcomitant medications 
 


 
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6.13. 
Visit 10 (Day 23, +/- 2 days, Phone/Home Visit) 
 Urine collection for metabolomics 
 Fecal sample collected for research  measurements, including microbial and 
metabolomic composition 
 Adverse events 
 Concomitant medications 
 
6.14. 
Visit 11 (Day 30, +/- 2 Days; ~ 4 weeks post FMT) 
The following procedures are conducted during this visit.   
 Brief physical examination  
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Weight 
 Fasting blood collection for metabolomics and flow cytometry 
 Modified 2-hour oral glucose tolerance test 
 Urine collection for metabolomics 
 Dietitian visit to review 3-day diet record, with directions to repeat prior to visit 14 
 Download Fitbit data 
 Fecal sample collected for research measurements, including microbial and metabolomic 
composition 
 Clinical labs including liver function tests, fasting lipid panel, CRP level, creatinine 
level, blood glucose 
 Adverse events  
 Concomitant medications 
 
6.15. 
Visit 12 (Day 34, +/- 5 Days) 
 Weight 
 Urine pregnancy test for women of childbearing potential 
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 fMRI (optional) 
 Hepatic MRI (optional) 
 iDXA 
 Download Fitbit data 
 Adverse events 
 Concomitant medications 
 
6.16. 
Visit 13 (Day 41, +/- 5 Days) 
 Urine pregnancy test for women of childbearing potential 
 Weight 
 Resting metabolic rate assessment 
 6-hour insulin clamp (option for 3-hour clamp if participant does not consent for 6-hour 
procedure) 
 Clinical labs including hepatic panel, fasting lipid panel, CRP level 
 Download Fitbit data 
 Adverse events 


 
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 Concomitant medications 
 
 
6.17. 
Visit 14 (Day 45, +/- 1 Week) or Early Termination 
The following procedures are conducted during this visit.   
 Complete physical examination  
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Weight 
 Fasting blood collection for metabolomics and flow cytometry 
 Clinical labs including fasting lipid panel, blood glucose 
 Urine collection for metabolomics 
 Dietitian visit to review 3-day diet record. 
 NCI DHQ II to assess mean dietary intake from baseline to approximately 5 weeks post-
intervention. 
 Fecal sample collected for research measurements, including microbial and metabolomic 
composition. 
 Download Fitbit data 
 Retrieve Fitbit from subject 
 Adverse events 
 Concomitant medications 
 
 
6.18. 
Visit 15 (Day 180 +/-1 Week) Safety Follow-Up 
 Complete physical examination  
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Weight 
 Fasting blood collection for metabolomics and flow cytometry 
 Clinical labs including fasting lipid panel, blood glucose 
 Modified 2-hour oral glucose tolerance test 
 Urine collection for metabolomics 
 Fecal sample collected for research  measurements, including microbial and 
metabolomic composition 
 NCI DHQ II to assess mean dietary intake post-intervention 
 Adverse events 
 Concomitant medications 
 
6.19. 
Unscheduled Visits  
If at any time an unscheduled visit, including phone calls, should occur throughout the 
duration of the study, the following procedures will be completed. 
 Adverse Events 
 Concomitant medications 
 Ask for any concerns about study procedures  
 Physical examination and review of medical history as needed 
 Order any lab tests as clinically indicated 


 
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6.20. 
Lean Donor Clinical/Laboratory Evaluations 
Eligible donors will be enrolled from the Fecal Microbiota Donor Screening program.  
These individuals are ideal as they are already pre-screened, have no chronic diseases, 
and are already familiar with the process of stool collection.  Consent will be obtained 
before any clinical evaluations are performed.  Donors will undergo clinical/laboratory 
testing per the FMT Donor Screening protocol (as described in our IND 15071). Donors 
will also undergo additional clinical/laboratory evaluations to establish baseline 
measurements for comparison to subjects enrolled in the study.  The following 
procedures will be collected over the course of two visits (within a 10 day period): 
 
 Thorough review of the study, including involved procedures 
 Medical history, including medications over the previous 12 months, and 
demographics 
 Complete physical examination  
 Vital signs (heart rate, temperature, blood pressure, respiration rate) 
 Height and weight 
 Possible repeat of fasting glucose, HgbA1C, or oral 2-hour glucose tolerance 
test if recent (< 6 months) results are not available 
 Urine pregnancy test for women of childbearing potential 
 Fasting blood collection for metabolomics and flow cytometry 
 Clinical labs including fasting lipid panel  
 Urine collection for metabolomics 
 Dietitian assessment 
 NCI DHQ II to assess baseline of diet of the donor 
 Resting metabolic rate assessment 
 Insulin clamp 
 Modified 2-hour oral glucose tolerance test 
 iDXA 
 Adverse events 
 Concomitant medications 
 
The donors will come in for as many donation visits as is necessary to obtain sufficient 
material for the study.  Donor material will be collected and processed via the protocol 
for the FMT Donor Screening program. 
 
6.21. 
Specimen Preparation, Handling, and Storage for Metabolomics 
Subjects will collect a first morning urine sample in a sterile container. The subjects will 
be provided all the supplies for urine collection, including 50 mL containers and coolers 
for transport.   
 
Blood will be collected in the clinic in Vacutainer Blood Collection Tubes containing 
approximately 1.8 mg K2EDTA per mL of blood as anticoagulant. The tubes will be 
inverted carefully 10 times to mix blood and anticoagulant, and kept at room 
temperature until centrifugation, which will be done within 15 minutes of collection. 


 
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Centrifugation will be carried out for 10 minutes at 13 RCF (relative centrifugal force) at 
room temperature. The top layer will be collected and frozen at -80oC. 
 
Participants will provide and store fecal samples at home 1 day prior to a scheduled visit 
or will provide a sample at the study site on the day of the visit. Participants collecting 
samples at home will be provided with all necessary supplies and will be instructed to 
store samples in a freezer prior to bringing to the study site. Fecal samples will be 
collected in a toilet hat and split upon receiving from participant. A 1.5 gram sample 
from the center of the specimen will be mixed with RNAprotect® solution and frozen in 
liquid nitrogen within 15 minutes of collection. The remainder of fecal specimens 
collected on-site as well as a portion of fecal specimens collected at home will be 
transferred into sterile containers. Specimens will be put in the freezer until transfer to 
the investigator’s lab. 
 
The investigator’s lab will store all of the stool samples as well as the urine and blood 
samples collected for metabolomics.  This laboratory is located at: 
 
          
Medical Biosciences Building 
University of Minnesota 
     
 
2101 6th Street SE 
Minneapolis, MN 55414 
 
6.22. 
Modified 2-Hour Oral Glucose Tolerance Test (MOGTT)   
An IV catheter will be inserted into an antecubital vein for blood sampling and kept 
patent with a continuous infusion of saline. Blood samples to determine plasma glucose, 
insulin, and C-peptide concentrations will be collected 10 and 5 min immediately before 
ingesting a 75-gram glucose load and at 10, 20, 30, 60, 90, and 120 min after glucose 
ingestion. The total areas under the curve for glucose, insulin, and C-peptide 
concentrations will be calculated by using the trapezoid method.  Insulin sensitivity will 
be assessed by using the oral glucose insulin sensitivity index (Mari et al., 2001). Indices 
of β-cell function will be estimated from plasma glucose and C-peptide concentrations 
by using the oral minimal model of C-peptide secretion and kinetics (Mari et al., 2001; 
Breda et al., 2002).  This model calculates the insulin secretion rate as a function of time 
and the following indices of β-cell responsivity: (i) dynamic responsivity index 
(Φd(109)), which is an index of insulin secretion in response to the rate of change in 
glucose concentration; (ii) static responsivity index (Φs(109min-1)), which is an index of 
insulin secretion in response to a given glucose concentration; and (iii) overall 
responsivity index (Φo (109min-1)), which is a global sensitivity to glucose index of 
postprandial insulin secretion.  The MOGTT will be performed a Visits 1, 11, and 15. 
 
6.23. 
Insulin Sensitivity Assessment with 6-Hour Hyperinsulinemic-Euglycemic Clamp 
 
Subjects will be admitted to the clinical research unit at Visit 3 and Visit 13. After 
subjects have fasted overnight, a catheter will be inserted into a hand or forearm vein to 
obtain blood samples, and into an antecubital vein of the contralateral arm to infuse 
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hyperinsulinemic-euglycemic clamp procedure with stable-isotopically labeled glucose 
tracer will be initiated to determine insulin sensitivity.  After baseline blood samples are 
obtained, a primed-constant infusion of [6,6-2H2]glucose (22 µmol/kg prime and 0.22 
µmol.kg-1.min-1 constant infusion) will be started at t=0 min and continued throughout 
the clamp procedure.  At 1000 h, after the basal period is completed, a one-stage 
euglycemic, hyperinsulinemic clamp will be initiated and continued for 3 h. Euglycemia 
will be achieved by a variable rate infusion of 20% dextrose enriched to approximately 
2.5% with [6,6-2H2]glucose to minimize changes in glucose isotopic enrichment.  Insulin 
will be infused at a rate of 40 mU.m2.min-1 for 3 h (initiated with a two-step priming 
dose of 200 mU.m2.min-1 for 5 min followed by 100 mU.m2.min-1 for 5 min). The 
infusion of [2H2]glucose will be stopped completely at the start of the insulin infusion.  
Plasma samples will be taken before beginning the isotope infusion to obtain baseline 
measurements of substrate enrichment. Plasma samples will be taken every 10 min 
during the last 30 min of the basal period and the insulin clamp to determine glucose 
concentrations and kinetics, and plasma insulin concentrations. Plasma samples will be 
obtained every 10 min at the end of the basal period and throughout the entire clamp 
period to monitor plasma glucose concentration.  
 
6.24. 
Insulin Sensitivity Assessment with 3-Hour Hyperinsulinemic-Euglycemic Clamp 
The 3-hour insulin clamp will be performed at Visit 3 and Visit 13 if a participant does 
not consent for the 6-hour procedure. After an overnight fast, two peripheral IVs will be 
placed (1 in each arm), with one IV used for infusion, and one IV used for blood 
sampling. Starting at time 0, insulin will be infused at 1.0 mU/kg FFM/min, along with a 
potassium infusion (KPO4 at 50 ml/hr) and dextrose infusion (Dextrose 20%, titrated to 
maintain the blood glucose at 85-95 mg/dl). Serum blood glucose will be measured 
every 10 minutes (Analox, United Kingdom) and insulin will be measured every 30 
minutes. 
 
 
6.25. 
Dietary Follow-up  
Dietary intake data will be collected throughout the study to estimate total energy intake 
and composition of macro- and micronutrient intake. Two methods of dietary 
assessment will be used: food frequency questionnaires (FFQs) and 3-day diet records. 
The National Cancer Institute’s Diet History Questionnaire II (DHQ II) is a freely 
available FFQ and has a food list consisting of 134 food items and 8 dietary supplement 
questions (see Appendix 2). A web-based version of the DHQ II will be completed by 
subjects at visits 1 (Day -31), 14 (Day +45), and 15 (Day +180). Three-day diet records 
will be completed by subjects at 8 time points (immediately prior to visits 1 (baseline), 
4, 5, 6, 8, 9, 11, and 14). A research dietitian trained and certified in the University of 
Minnesota’s Nutrient Data System for Research (NDSR) dietary interviewing and 
assessment protocols will instruct subjects on methods for accurate assessment and 
recording of dietary intake, and will follow up with subjects at each of the above listed 
time points and additionally as needed. DHQ II data will be analyzed with Diet*Calc 
software developed by the NCI. Analysis of 3-day diet records will be performed using 
NDSR data output.  
 


 
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6.26. 
Resting Metabolic Rate Assessment  
Resting metabolic rate (RMR) will be assessed via indirect calorimetry using a 
ParvoMedics True One 2400 metabolic cart with a canopy hood. The procedure will be 
conducted at the CTSI by trained technicians, and each assessment is approximately 60 
minutes in duration. This will be done during the insulin clamp at Visit 3 and Visit 13. 
 
6.27. 
Fitbit Data Collection 
Subjects will be provided a Fitbit at Visit 1, set up their account with the assistance of 
the Study Coordinator to ensure proper privacy settings, and be given instructions on 
use.  Fitbit data that is automatically collected includes, but is not limited to: steps taken, 
distance, calories burned, active minutes, and data on sleep habits, including time slept, 
quality of sleep, and number of times an individual wakes in the night.  Additional 
manual entry of health data can be entered into the Fitbit Dashboard, including: weight, 
blood pressure, heart rate, diet, exercise, and water consumption.  Fitbit data will be 
downloaded in person with the Study Coordinator at visits 2, 3, 4, 5, 8, 11, 12, 13, and 
14, and stored on University of Minnesota secure servers. 
 
Fitbit is HIPAA compliant and offers personalized privacy settings.  The study team will 
assist the subjects with privacy settings to ensure their data is secure and not made 
available to the public.  
 
6.28. 
Hepatic Magnetic Resonance Imaging 
Hepatic MRI imaging will be an optional procedure in this study. A hepatic proton 
density fat fraction by using the Siemens Prisma 3T Magnetic Resonance Imaging 
(MRI) scanner will be performed. This technique has been validated to determine 
percentage of hepatic steatosis and correlates with findings on liver biopsy (Reeder and 
Sirlin, 2010). The MRI will be performed at Visit 2 and Visit 12. 
 
6.29. 
Functional Magnetic Resonance Imaging 
fMRI imaging will be an optional procedure in this study. Subjects will be scanned 
using the Siemens Prisma 3T MRI scanner.  After automated scout and shimming 
procedures, high resolution T1-weighted structural scans will be collected.  The fMRI 
images, i.e., BOLD signal, will be acquired using echo planar (T2*-weighted) sequences 
(repetition time [TR] = 710ms, echo time = 30 ms, flig angle 52, slice thickness = 2 mm; 
72 sequential axial slices, oriented along the anterior-posterior commissure line).  Note: 
the exact scanner parameters may change depending on protocol optimization.  In 
addition to the functional imaging scans, structural imaging scans will be collected for 
localization, slice selection, and image registration purposes.  Three visual tasks will be 
presented over separate scanning runs: (1) low-calorie foods, (2) high-calorie foods, and 
(3) nonedible food-related utensils, as described previously (Killgore et al., 2003). The 
fMRI will be performed at Visit 2 and Visit 12. 
 
6.30. 
iDXA Dual X-ray Absortiometry 
Body composition and body fat distribution will be assessed by dual-energy X-ray 
absorptiometry (DXA) in the total body-scanning mode with an iDXA apparatus ( GE 


 
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Healthcare Lunar IDXA enCore software version 16 ) at the Delaware Clinical Research 
Unit (DCRU). The Lunar iDXA has demonstrated excellent precision for total body 
measurements of body composition, total body fat, and percent total body fat. The iDXA 
procedure will be performed at Visit 2 and Visit 12. 
 
6.31. 
Subject Compensation 
Subjects will be compensated for their time and travel costs for study visits.  
Compensation amounts are specified in the study’s consent form. 
 
7.  
SAFETY AND ADVERSE EVENTS 
7.1. Definitions 
Adverse Event (AE) 
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 will be regarded as 
adverse events.  Abnormal results of study procedures are considered to be AEs if the 
abnormality: 
 
Results in study withdrawal 
 
Is associated with a serious adverse event (SAE) 
 
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. 
 
Adverse Reaction 
An adverse reaction is any adverse event caused by the investigational agent.  Adverse reactions 
are a subset of suspected adverse reactions. 
 
Suspected Adverse Reaction 
A suspected adverse reaction is an adverse event for which there is a reasonable possibility that 
the investigational agent caused the adverse event. 
 
Serious Adverse Event (SAE) 
A serious adverse event (SAE) is any adverse event that is: 
 
Fatal 
 
Life-threatening 
 
Requires or prolongs a hospital stay 
 
Results in persistent or significant disability or incapacity 
 
A congenital anomaly or birth defect 
 
Important medical events are events that may not be immediately life-threatening, but are 
clearly of major clinical significance and may be SAEs.  They may jeopardize the subject, and 
may require intervention to prevent one or the other serious outcomes noted above.   
 
Hospitalization  
Hospitalization shall include any initial admission (even if less than 24 hours) to a healthcare 
facility as a result of a precipitating clinical adverse event; to include transfer within the hospital 


 
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to an intensive care unit.  Hospitalization or prolongation of hospitalization in the absence of a 
precipitating, clinical adverse event (e.g., for a preexisting condition not associated with a new 
adverse event or with a worsening of the preexisting condition; admission for a protocol-
specified procedure) is not, in itself, a serious adverse effect. 
 
Expected Adverse Event 
Expected adverse events are those that are known to be associated with or have the potential to 
arise as a consequence of participation in the study. 
 
Unexpected Adverse Event 
An adverse event or suspected adverse reaction is considered unexpected if it is not listed in the 
Protocol at the specificity or severity that has been observed. 
 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
An adverse event that in the opinion of the Principal Investigator is unexpected and related to 
the investigational agent. 
 
Assessment of Severity 
The sponsor-investigator will make an assessment of severity for each AE and SAE reported 
during the study. The assessment will be based on the sponsor-investigator’s clinical judgment. 
The severity of each AE recorded will be assigned a severity based on Common Terminology 
Criteria for Adverse Events (CTCAE) grading. 
 
Assessment of Causality 
The sponsor-investigator will estimate the relationship between the investigational agent and the 
occurrence of each AE or SAE by using his best clinical judgment. Other elements, such as the 
history of the underlying disease, concomitant therapy, other risk factors, and the temporal 
relationship of the event to administration of the investigational agent, will be considered and 
investigated.  
 
An SAE may be recorded when the sponsor-investigator has minimal information to include in 
the initial report.  The sponsor-investigator may change his opinion of the causality in light of 
follow-up information, with subsequent amendment of the SAE report.  
 
 
Categories 
Definition 
Definitely related 
This relationship suggests that a definite 
causal relationship exists between the 
administration of the investigational agent 
and the AE, and other conditions 
(concurrent illness, progression/expression 
of disease state, or concurrent medication 
reaction) do not appear to explain the 
event. 
Probably related 
This relationship suggests that a reasonable 
temporal sequence of the event with 


 
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investigational agent administration exists 
and, based upon the known or previously 
reported adverse reactions, or judgment 
based on the investigator’s clinical 
experience, the association of the event 
with the investigational agent seems likely. 
Possibly related 
This relationship suggests that treatment 
with the investigational agent may have 
caused or contributed to the AE (i.e., the 
event follows a reasonable temporal 
sequence from the time of investigational 
agent administration and/or follows a 
known response pattern to the 
investigational agent but could also have 
been produced by other factors.) 
Not related 
This relationship suggests that there is no 
association between the investigational 
agent and the reported event. 
 
 
7.2. Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse events by 
specific questioning, reviewing the adverse events diary card, and, as appropriate, by 
examination.  Information on all adverse events will 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 will be recorded in 
the source document, though should be grouped under one diagnosis. 
 
The clinical course of each event will be followed until resolution, stabilization, or until it has 
been determined that the study treatment or participation is not the cause.  Serious adverse 
events will be collected for the six month period following study product administration.  
Serious adverse events that are still ongoing at the end of the study period will 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 will be recorded 
and reported immediately. 
 
The study’s medical monitor will review adverse events data every 6 months. 
 
Expected adverse events include: 
 Events associated with venipunctures. 
o Discomfort and slight bruising. 
 Events associated with colonoscopy. 
o Diarrhea during the preparation 
o Discomfort during the colonoscopy procedure 
o Inability to drive for 24 hours following the colonoscopy due to administration of 
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 Events associated to insulin clamp, mitigated by physician supervision and sugar 
administration. 
o Low blood sugar 
o Sweating 
o Weakness 
 Events associated with MRI scanning. 
o Discomfort associated with laying still 
o Dizziness, mild nausea, headache associated with loud noises and sensations of 
flashing lights in the scanner 
 
Possible, although unlikely, adverse events that may be encountered include: 
 Events associated with venipunctures. 
o Bruising 
o Bleeding 
o Lightheadedness, fainting 
o Infection at the venipuncture site 
o Nausea 
o Anxiety 
o Swelling at the venipuncture site 
 Events associated with antibiotic administration. 
o Nausea, abdominal discomfort. 
o Diarrhea 
o Allergic reaction 
 Events associated with colonoscopy. 
o Nausea during the preparation to the examination 
o Bleeding from the colon, particularly at sites of biopsies or incidental polyp 
removal 
o Tear in the colon wall 
 Events associated with MRI scanning. 
o Severe anxiety or claustrophobia associated with being in a confined space 
 
7.3. Reporting of Serious Adverse Events 
 
7.3.1. IRB Notification by Sponsor-Investigator 
Reports of all serious adverse events (including follow-up information) must be submitted to the 
IRB within the reporting timeline requirements, if the SAE falls under the UPIRTSO guidelines.  Copies 
of each report and documentation of IRB notification and receipt will be kept in the Clinical 
Investigator’s binder. 
 
7.3.2. FDA Notification by Sponsor-Investigator 
The study sponsor-investigator shall notify the FDA by telephone or by facsimile (preferred) 
transmission of any unexpected fatal or life-threatening experience associated with the use of the 
investigational agent as soon as possible but no later than 7 calendar days from the sponsor-
investigator’s original receipt of the information. 
 


 
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If a previous adverse event that was not initially deemed reportable is later found to fit the 
criteria for reporting, the study sponsor-investigator will submit the adverse event in a written report to 
the FDA as soon as possible, but no later than 15 calendar days from the time the determination is made. 
 
7.3.3. UPIRTSO Events 
Upon first learning of a UPIRTSO event, investigators are required to submit a report of the 
applicable event(s) to the IRB within the required reporting timeline.   
 
8.  
CLINICAL MANAGEMENT OF EVENTS 
 
8.1. Adverse Event Management 
If an adverse event occurs that requires clinical management, the subject will be evaluated at an 
Unscheduled Study Visit with a physical exam.  Tests and treatments that may be clinically 
indicated will be ordered.  
 
8.2. Temporary Interruption of Study Product in an Individual Subject 
Subjects will receive one administration of the fecal microbiota.  No temporary interruption of 
study product in an individual subject will occur. 
 
9.  
CLINICAL SITE MONITORING PLAN 
Independent monitoring of the clinical study for compliance will be conducted periodically (i.e., 
at a minimum of annually) by qualified staff of the University of Minnesota’s CTSI in 
accordance with the established monitoring plan. 
 
10. 
STATISTICAL CONSIDERATIONS 
10.1. 
Study Hypotheses 
The central hypothesis for this study is that implantation of microbiota from lean donors 
without any features of metabolic syndrome will improve insulin sensitivity in pre-
diabetic subjects.  Fecal microbiota transplant will increase the fecal microbial diversity 
and enhance the ability of gut microbiota to produce mediators, such as short-chain fatty 
acids.  These mediators have the potential to alter subject appetite and food cravings, 
metabolic rate, and responsiveness to insulin. We further hypothesize that antibiotic 
conditioning regimen will increase engraftment of donor phylotypes by FMT over a 
placebo conditioning regimen.  
 
10.2. 
Sample Size Considerations 
This feasibility study plans to enroll 24 subjects who will be randomly assigned to 
receive antibiotic conditioning or placebo using a 1:1 ratio.  We anticipate that 4 subjects 
may drop out from the study for various reasons, including inability to comply with the 
rigorous study visit schedule or new medical problems unrelated to the study, e.g., use of 
antibiotics for an infection.  Study enrollment is intentionally limited to prevent 
unnecessary risk in this population until the study feasibility has been determined.  This 
pilot study is similar in size to an earlier report by Vrieze and colleagues where 18 
subjects with metabolic syndrome were randomized to receive lean or their own fecal 
microbiota (placebo) via duodenal tube lavage, with improvement in peripheral insulin 
sensitivity documented at 6 weeks (Vrieze et al., 2012). Some of the differences in the 


 
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present study include (1) randomization to antibiotic conditioning versus placebo prior to 
FMT (2) colonoscopic administration of fecal microbiota rather than nasoduodenal 
infusion, and (3) longer follow-up of subjects.   
 
We will compare post-FMT insulin sensitivity between the two groups (antibiotic versus 
placebo conditioned) using a two-sample t-test: 10 subjects/arm should yield a detectable 
difference of 3.51 units in Glucose Infusion Rate (GIR) (80% power) and 4.05 units in 
GIR (90% power).  In addition, we will use paired t-tests to test whether post-FMT 
insulin sensitivity increased within each group by comparing pre- and post-FMT insulin 
tests for each subject. 
 
An intent to treat (ITT) population will include all patients randomized and analyzed 
according to the treatment assigned.  Evaluation of the safety profile will be primarily 
descriptive in nature including frequency, type, and severity of adverse events by 
treatment arms.  Descriptive analyses of baseline characteristics and outcomes across the 
two treatment groups will include means and standard deviations for continuous variables 
and frequencies for categorical variables. Exploratory analyses will use an ANCOVA 
style regression for comparing the difference between the treatment arms for continuous 
measures while adjusting for the baseline measure. For continuous measures with outliers 
or skewed distributions, a Wilcoxon rank-sum test will be used to compare the treatment 
arms.  A binomial exact test will be used to compare the difference in proportions 
between the two arms. 
 
Comparison of donor microbiota engraftment efficiency will be performed using a 
number of assays, including an estimate of percent engraftment using SourceTracker 
software (Knights et al., 2011), which is based on a Bayesian approach to estimate 
microbial community origins, quantification of donor-specific operational taxonomic 
units, functional analysis of pre- and post-FMT microbial communities using PICRUSt 
software (Phylogenetic Investigation of Communities by Reconstruction of Unobserved 
States) (Langille et al., 2013), and pre- and post-FMT fecal metabolome analysis.  The 
combination of these analytical methods should determine superiority of one protocol 
over another in achieving greater similarity of post-FMT microbiota to donor material, 
although given the exploratory nature of this work and its rapidly evolving methodology 
it is difficult to make meaningful power calculations at this stage on the engraftment 
objective.  Nevertheless, failure to distinguish antibiotic versus placebo conditioning 
prior to FMT using these methods will be sufficient to determine that our chosen 
antibiotic conditioning regimen is not beneficial to enhancement of microbiota 
engraftment.  
 
10.3. 
Randomization 
Randomization will occur in a 1:1 ratio in the IDS pharmacy between antibiotics and 
placebo formulations. 
 
10.4. 
Blinding 
Both the treatment personnel and the subject will be blinded.  To maintain blinding, the 
drug packaging will be identical between the two groups.  


 
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10.5. 
Planned Interim Analyses  
No interim analyses are planned for this study. 
 
10.6. 
Safety Review  
To minimize risk, cumulative safety data will be reviewed by the sponsor-investigator 
and an independent medical monitor at a minimum of every six months or more 
frequently should an urgent situation arise. This safety monitoring will include careful 
assessment and appropriate reporting of adverse events as noted above, using adverse 
events source documents and records kept in the study’s web-based data entry system.  
Medical monitoring will include a regular assessment of the number and type of serious 
adverse events. Study enrollment and dosing will be stopped and an ad hoc review will be 
performed if any of the following occurs: 
1. Death of an enrolled subject when the cause is considered to be “related” to FM; 
2. Occurrence of a life-threatening allergic/hypersensitivity reaction (anaphylaxis), 
manifested by bronchospasm with or without urticaria or angioedema;  
3. An overall pattern of symptomatic, clinical, or laboratory events that the sponsor-
investigator, scientific liaisons, regulatory affairs manager and statistician 
consider associated with study product and that may appear minor in terms of 
individual events but that, collectively, may represent a serious potential concern 
for safety; 
4. Any SAE that is possibly, probably, or definitely related to study product 
administration; 
5. Two or more subjects experience the same CTCAE Grade 3 or higher adverse 
event that is possibly, probably, or definitely related to study product 
administration. 
 
10.7. 
Final Analysis Plan  
An ITT population will include all patients randomized and analyzed according to the 
treatment assigned.  Evaluation of the safety profile will be primarily descriptive in 
nature including frequency, type, and severity of adverse events by treatment arms.  
Descriptive analyses of baseline characteristics and outcomes across the two treatment 
groups will include means and standard deviations for continuous variables and 
frequencies for categorical variables.  Exploratory analyses will use an ANCOVA style 
regression for comparing the difference between the treatment arms for continuous 
measures while adjusting for the baseline measure.  For continuous measures with 
outliers or skewed distributions, a Wilcoxon rank-sum test will be used to compare the 
treatment arms.  A binomial exact test will be used to compare the difference in 
proportions between the two treatment arms. 
 
11. 
DATA HANDLING / RECORD KEEPING / SOURCE DOCUMENTS 
11.1. 
Data Capture Methods 
Clinical data (including AEs and concomitant medications) and clinical laboratory data 
will be entered into an internet data entry system provided by the Clinical and 
Translational Science Institute. The data system includes password protection and 


 
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internal quality checks to identify data that appear inconsistent, incomplete, or inaccurate. 
Clinical data will be entered directly from the source documents.  
 
11.2. 
Types of Data 
Data for this study will include safety, laboratory and outcome measures. 
 
11.3. 
Study Records Retention  
Per University of Minnesota policy all documents concerning the use of human subjects 
in research will be maintained for at least 3 years from completion of IRB-related work 
and at least 6 years for HIPAA. No record will be destroyed without the written consent 
of the sponsor-investigator. 
 
The sponsor-investigator will permit authorized representatives of the University of 
Minnesota and regulatory agencies to examine (and when required by applicable law, 
copy) clinical records for the purposes of clinical site monitoring, quality assurance 
reviews, audits, and evaluation of the study safety and progress.  
 
11.4. 
Source Documents 
A source document is defined as the location where study-related data are initially 
recorded.  Source documents for this study will include hard copy paper and/or electronic 
forms, laboratory printouts, and medical records onto or into which data will first be 
recorded. 
 
11.5. 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol.  The 
noncompliance may be either on the part of the subject, the investigator, or the study site 
staff.  As a result of deviations, corrective actions are to be developed by the site and 
implemented promptly.  
 
When a deviation from the protocol is necessary for an individual subject, the 
Investigator must complete a description of the deviation from the protocol and 
justification on the Protocol Deviation Form. It will not be considered a protocol 
deviation if a subject is unable to provide a stool sample at any visit that requires a stool 
sample.  
 
12. 
QUALITY CONTROL AND QUALITY ASSURANCE 
The investigative site will document any internal reviews of the conduct of the protocol.  
 
13. 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
13.1. 
Ethical Standard 
The investigator(s) will ensure that this study is conducted in conformity with the 
principles of The Belmont Report: Ethical Principles and Guidelines for the Protection of 
Human Subjects of Research of The National Commission for the Protection of Human 
Subjects of Biomedical and Behavioral Research (April 18, 1979) and codified in 45 CFR 
46, 21 CFR 312, and/or ICH E6; 62 Federal Regulations 25691 (1997).  The University 


 
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of Minnesota holds a current federal-wide assurance (FWA) issued by OHRP for 
federally funded research. 
 
13.2. 
Institutional Review Board 
The Human Subjects Protection Program at the University of Minnesota will be asked to 
review and approve this protocol, associated consent documents, and recruitment 
materials. Approval of any amendments to the protocol or consent materials will also be 
requested before they are implemented.  
 
14. 
INFORMED CONSENT PROCESS 
The informed consent process will be initiated before a volunteer agrees to participate in the 
study and will continue throughout the individual’s study participation.  The subject will sign the 
informed consent document before any procedures are undertaken for the study.  A copy of the 
signed informed consent document will be given to the subject for his/her records.  The consent 
will explain that subjects may withdraw consent at any time throughout the course of the trial.  
Extensive explanation and discussion of risks and possible benefits of this investigation will be 
provided to the subjects in understandable language.  Adequate time will be provided to ensure 
that the subject has time to consider and discuss participation in the protocol.  
 
The consent form will describe, in detail, the study interventions / products / procedures and 
risks / benefits associated with participation in the study.  The rights and welfare of the subjects 
will be protected by emphasizing that their access to and the quality of medical care will not be 
adversely affected if they decline to participate in this study. 
 
14.1. 
Subject Confidentiality 
Subject confidentiality is strictly held in trust by the participating investigator, his staff, 
and their agents.  This confidentiality includes documentation, investigation data, 
subject’s clinical information, and all other information generated during participation in 
the study. 
 
No information concerning the study or the data generated from the study will be released 
to any unauthorized third party without prior written approval of the sponsor and the 
subject. 
 
The study monitor or other authorized representatives of governmental regulatory 
agencies may inspect all documents and records required to be maintained by the 
investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the subjects in this study.  The clinical study site will permit access 
to such records. 
 
14.2. 
Principal Investigator Responsibility When Subject Withdraws or is Discontinued 
If a subject terminates the study early, and is willing, the tests and procedures that would 
occur at Visit 14 (Early Termination) will be done.  
 
14.3. 
Future Use of Stored Specimens  


 
Page 42 of 49 
Version 4.0 
Blood samples collected during the study will be sent to and processed by hospital 
laboratory personnel at University of Minnesota Medical Center, Fairview.  Blood will be 
discarded. 
 
Fecal and urine samples will be stored by the investigator’s laboratory for the purpose of 
purifying DNA for metagenomic analysis.  Fecal and urine samples will not be 
anonymized and will not be shared with other investigators.  The specimens may be 
stored in the investigator’s laboratory for up to 5 years.  No human genetic testing will be 
performed on these samples. 
 
Subjects may withdraw consent for fecal and urine sample storage.  If a subject 
withdraws consent samples will be destroyed.  Any data from fecal samples obtained 
prior to withdrawal of consent will be used in study results analysis.  
 
Subjects will be asked to agree to re-contact for future research on stored samples. 
 
15. 
PUBLICATION POLICY 
The International Committee of Medical Journal Editors (ICMJE) member journals has adopted 
a trials-registration policy as a condition for publication.  This policy requires that all clinical 
trials be registered in a public trials registry such as ClinicalTrials.gov, which is sponsored by the 
National Library of Medicine.  This protocol is registered on ClinicalTrials.gov as 
NCT02730962.  
 


 
Page 43 of 49 
Version 4.0 
16. LITERATURE REFERENCES 
 
Amar, J., Serino, M., Lange, C., Chabo, C., Iacovoni, J., Mondot, S., Lepage, P., Klopp, 
C., Mariette, J., Bouchez, O., et al. (2011). Involvement of tissue bacteria in the onset of 
diabetes in humans: evidence for a concept. Diabetologia 54, 3055-3061. 
 
Angelberger, S., Reinisch, W., Makristathis, A., Lichtenberger, C., Dejaco, C., Papay, P., 
Novacek, G., Trauner, M., Loy, A., and Berry, D. (2013). Temporal bacterial community 
dynamics vary among ulcerative colitis patients after fecal microbiota transplantation. 
Am J Gastroenterol 108, 1620-1630. 
 
Backhed, F., Ley, R.E., Sonnenburg, J.L., Peterson, D.A., and Gordon, J.I. (2005). Host-
bacterial mutualism in the human intestine. Science 307, 1915-1920. 
 
Blaser, M.J. (2006). Who are we? Indigenous microbes and the ecology of human 
diseases. EMBO Rep 7, 956-960. 
 
Breda, E., Toffolo, G., Polonsky, K.S., and Cobelli, C. (2002).  Insulin release in 
impaired glucose tolerance: oral minimal model predicts normal sensitivity to glucose but 
defective response times.  Diabetes 51, S227-233. 
 
Cani, P.D., Amar, J., Iglesias, M.A., Poggi, M., Knauf, C., Bastelica, D., Neyrinck, A.M., 
Fava, F., Tuohy, K.M., Chabo, C., et al. (2007). Metabolic endotoxemia initiates obesity 
and insulin resistance. Diabetes 56, 1761-1772. 
 
Cox, L.M., and Blaser, M.J. (2013). Pathways in microbe-induced obesity. Cell Metab 
17, 883-894. 
 
De Silva, A., Salem, V., Matthews, P.M., and Dhillo, W.S. (2012). The use of functional 
MRI to study appetite control in the CNS. Exp Diabetes Res 2012, 764017. 
 
De Vadder, F., Kovatcheva-Datchary, P., Goncalves, D., Vinera, J., Zitoun, C., 
Duchampt, A., Backhed, F., and Mithieux, G. (2014). Microbiota-generated metabolites 
promote metabolic benefits via gut-brain neural circuits. Cell 156, 84-96. 
 
Hamilton, M.J., Weingarden, A.R., Sadowsky, M.J., and Khoruts, A. (2012). 
Standardized frozen preparation for transplantation of fecal microbiota for recurrent 
Clostridium difficile infection. Am J Gastroenterol 107, 761-767. 
 
Killgore, W.D., Young, A.D., Femia, L.A., Bogorodzki, P., Rogowska, J., and Yurgelun-
Todd, D.A. (2003). Cortical and limbic activation during viewing of high- versus low-
calorie foods. Neuroimage 19, 1381-1394. 
 
Knights, D., Kuczynski, J., Charlson, E.S., Zaneveld, J., Mozer, M.C., Collman, R.G., 
Bushman, F.D., Knight, R., and Kelley, S.T. (2011). Bayesian community-wide culture-
independent microbial source tracking. Nature methods 8, 761-763. 


 
Page 44 of 49 
Version 4.0 
 
Langille, M.G., Zaneveld, J., Caporaso, J.G., McDonald, D., Knights, D., Reyes, J.A., 
Clemente, J.C., Burkepile, D.E., Vega Thurber, R.L., Knight, R., et al. (2013). Predictive 
functional profiling of microbial communities using 16S rRNA marker gene sequences. 
Nat Biotechnol 31, 814-821. 
 
Mari, A., Pacini, G., Murphy, E., Ludvik, B., and Nolan, J.J. (2001).  A model-based 
method for assessing insulin sensitivity from the oral glucose tolerance test.  Diabetes 
Care 24 (3), 539-548. 
 
Muccioli, G.G., Naslain, D., Backhed, F., Reigstad, C.S., Lambert, D.M., Delzenne, 
N.M., and Cani, P.D. (2010). The endocannabinoid system links gut microbiota to 
adipogenesis. Mol Syst Biol 6, 392. 
 
Musso, G., Gambino, R., and Cassader, M. (2011). Interactions between gut microbiota 
and host metabolism predisposing to obesity and diabetes. Annu Rev Med 62, 361-380. 
 
Qin, J., Li, Y., Cai, Z., Li, S., Zhu, J., Zhang, F., Liang, S., Zhang, W., Guan, Y., Shen, 
D., et al. (2012). A metagenome-wide association study of gut microbiota in type 2 
diabetes. Nature 490, 55-60. 
 
Reeder, S.B., and Sirlin, C.B. (2010). Quantification of liver fat with magnetic resonance 
imaging. Magn Reson Imaging Clin N Am 18, 337-357, ix. 
 
Ridaura, V.K., Faith, J.J., Rey, F.E., Cheng, J., Duncan, A.E., Kau, A.L., Griffin, N.W., 
Lombard, V., Henrissat, B., Bain, J.R., et al. (2013). Gut microbiota from twins 
discordant for obesity modulate metabolism in mice. Science 341, 1241214. 
 
Rossen, N.G., Fuentes, S., van der Spek, M.J., Tijssen, J., Hartman, J.H., Duflou, A., 
Lowenberg, M., van den Brink, G.R., Mathus-Vliegen, E.M., de Vos, W.M., et al. 
(2015). Findings from a Randomized Controlled Trial of Fecal Transplantation for 
Patients with Ulcerative Colitis. Gastroenterology. 
 
Shen, J., Obin, M.S., and Zhao, L. (2013). The gut microbiota, obesity and insulin 
resistance. Mol Aspects Med 34, 39-58. 
 
Stepanov, V., Stankov, K., and Mikov, M. (2013). The bile acid membrane receptor 
TGR5: a novel pharmacological target in metabolic, inflammatory and neoplastic 
disorders. J Recept Signal Transduct Res 33, 213-223. 
 
Tilg, H., and Moschen, A.R. (2014). Microbiota and diabetes: an evolving relationship. 
Gut 63, 1513-1521. 
 
Tremaroli, V., and Backhed, F. (2012). Functional interactions between the gut 
microbiota and host metabolism. Nature 489, 242-249. 
 


 
Page 45 of 49 
Version 4.0 
Turnbaugh, P.J., and Gordon, J.I. (2009). The core gut microbiome, energy balance and 
obesity. J Physiol 587, 4153-4158. 
 
Turnbaugh, P.J., Hamady, M., Yatsunenko, T., Cantarel, B.L., Duncan, A., Ley, R.E., 
Sogin, M.L., Jones, W.J., Roe, B.A., Affourtit, J.P., et al. (2009). A core gut microbiome 
in obese and lean twins. Nature 457, 480-484. 
 
Vrieze, A., Van Nood, E., Holleman, F., Salojarvi, J., Kootte, R.S., Bartelsman, J.F., 
Dallinga-Thie, G.M., Ackermans, M.T., Serlie, M.J., Oozeer, R., et al. (2012). Transfer 
of intestinal microbiota from lean donors increases insulin sensitivity in individuals with 
metabolic syndrome. Gastroenterology 143, 913-916 e917. 
 
Wikoff, W.R., Anfora, A.T., Liu, J., Schultz, P.G., Lesley, S.A., Peters, E.C., and 
Siuzdak, G. (2009). Metabolomics analysis reveals large effects of gut microflora on 
mammalian blood metabolites. Proc Natl Acad Sci U S A 106, 3698-3703. 
 
Yatsunenko, T., Rey, F.E., Manary, M.J., Trehan, I., Dominguez-Bello, M.G., Contreras, 
M., Magris, M., Hidalgo, G., Baldassano, R.N., Anokhin, A.P., et al. (2012). Human gut 
microbiome viewed across age and geography. Nature 486, 222-227. 


 
Page 46 of 49 
Version 4.0 
17. Appendix 1: Schedule of Events 
 
 
Pre-FMT 
 
Post-FMT 
Procedures 
Screening 
Baseline 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Visit 9 
Visit 10 
Visit 11  
Visit 12  
Visit 13 
Visit 14 
F1 
Visit 15 
  
-40 days 
Day -31 
± 5 days 
Day -25 
± 5 days 
Day -18 
± 5 days 
Day -14 
± 2 days 
Day -7 ± 
4 days 
Day 0 
Day 2 
Day 9 ± 1 
day 
Day 16 ± 
2 days 
Day 23 ± 
2 days 
Day 30 ± 
2 days 
Day 34 ± 
5 days  
 Day 41 
± 5 days 
Day 45 ± 
1 week 
Day 180 
± 1 week 
Obtain 
Consent 
X 
  
  
  
  
  
  
  
  
 
  
  
  
  
 
  
Medical 
History 
X 
  
  
  
  
  
  
  
  
 
  
  
  
  
 
  
Physical 
exam  
X 
  
  
  
 
X  
  
 
 X 
 
 
 X 
 
 
X 
X 
Vitals 
X 
  
 X 
 X 
X 
 X 
  
 X 
 
 
 X 
 
 
X 
X 
Height 
X 
  
  
  
  
  
  
  
  
 
 
  
  
  
 
  
Weight 
X 
 X 
X 
 X 
X 
 X 
  
X  
 
 
X 
X 
X 
X 
X 
Clinical 
Labs  
X F2 
X F3 
  
 X 
  
  
 X 
  
X  
 
 
 X 
  
X  
X 
 X 
Urine 
Pregnancy 
test F4 
 
X 
 
 
X 
X 
 X 
  
  
 
  
 
  
 X 
 
  
Fasting 
Blood for 
Metabolo- 
mics 
  
X 
  
  
 
X  
  
 
 X 
 
 
X  
 
 
X 
X 
Urine 
sample 
collection  
  
X 
X  
 X 
  
 X 
 
X 
X 
X 
X 
 X 
 
 
X 
X 
Provide 
stool 
sample  
  
X 
 X 
 X 
  
 X 
 
X 
X 
X 
X 
 X 
 
 
X 
X 
Food 
frequency 
questionn-
aire 
  
X 
  
  
  
  
  
  
  
 
  
  
 
 
X 
X 


 
Page 47 of 49 
Version 4.0 
 
Pre-FMT 
 
Post-FMT 
Procedures 
Screening 
Baseline 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
Visit 9 
Visit 10 
Visit 11  
Visit 12  
Visit 13 
Visit 14 
F1 
Visit 15 
  
-40 days 
Day -31 
± 5 days 
Day -25 
± 5 days 
Day -18 
± 5 days 
Day -14 
± 2 days 
Day -7 ± 
4 days 
Day 0 
Day 2 
Day 9 ± 1 
day 
Day 16 ± 
2 days 
Day 23 ± 
2 days 
Day 30 ± 
2 days 
Day 34 ± 
5 days  
 Day 41 
± 5 days 
Day 45 ± 
1 week 
Day 180 
± 1 week 
Provide 
food diary 
X 
X 
 
 
X 
 X 
X 
 
X 
 
 
X  
  
  
 
  
Review 
food diary 
  
X 
  
 
X 
X 
 X 
 
X 
X 
 
 X 
 
  
X 
  
Fitbit 
  
  
X 
 X 
X 
 X 
  
 
 X 
 
 
X 
X 
 X 
X 
  
Insulin 
Clamp 
F5 
  
  
 
 X 
  
  
  
  
  
 
  
 
  
 X 
 
  
MOGTT 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
X 
RMR 
  
  
  
X 
  
  
  
  
  
 
  
  
 
 X 
 
  
fMRI 
  
  
X 
  
  
  
  
  
  
 
  
 
 X 
  
 
  
Hepatic 
MRI 
  
  
X 
  
  
  
  
  
  
 
  
 
 X 
  
 
  
iDXA 
  
  
X 
  
  
  
  
  
  
 
  
 
 X 
  
 
  
Start 
antibiotics
or placebo 
  
  
  
 
 X 
  
  
  
  
 
  
  
  
  
 
  
Colono-
scopy F6 
  
  
  
  
  
 
X  
  
  
 
  
  
  
  
 
  
Fecal 
microbiota 
transplant 
(FMT) 
  
  
  
  
  
 
 X 
  
  
 
  
  
  
  
 
  
Adverse 
Events/ 
Con meds 
  
X 
X 
 X 
X 
X 
X 
X 
X 
X  
X 
X  
X 
X 
X 
X 
 


 
Page 48 of 49 
Version 4.0 
F1. This visit will also be performed if early termination. 
F2. Possible repeat of fasting glucose, HgbA1C, or oral 2-hour glucose tolerance test if recent (< 6 months) results are not available. 
Creatinine if results not available within one month.  
F3. Clinical labs include: LFTs (including AST, ALT, alk phos), fasting lipid panel, CRP at Baseline Visit and Visit 11. Creatinine at Visit 
11. 
F4. For woman of child bearing potential only.   
F5. 6--hour insulin clamp. Subjects may opt for a shorter 3-hour clamp. 
F6. Colonoscopy prep will take place the day before FMT. 
 
 


 
Page 49 of 49 
Version 4.0 
 
18. Appendix 2:  Diet History Questionnaire II 
 
The NCI Diet History Questionnaire II is included on the following pages. 
 


This is a sample form.  Do not use for scanning. 
 
1 
NATIONAL INSTITUTES OF HEALTH 
 
Diet History Questionnaire II 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Today's date: 
 
MONTH 
DAY 
YEAR 
  
 Jan 
  
 Feb 
  
 Mar 
  
 Apr 
  
 May 
  
 Jun 
  
 Jul 
  
 Aug 
  
 Sep 
  
 Oct 
  
 Nov 
  
 Dec 
|___|___| 
 2010 
 2011 
 2012 
 2013 
 2014 
 2015 
 2016 
 2017 
 2018 
 2019 
 2020 
 
0 
0 
1 
1 
2 
2 
3 
3 
 
4 
 
5 
 
6 
 
7 
 
8 
 
9 
 
 
 
 
 
In what month were 
you born? 
 
  
 Jan 
  
 Feb 
  
 Mar 
  
 Apr 
  
 May 
  
 Jun 
  
 Jul 
  
 Aug 
  
 Sep 
  
 Oct 
  
 Nov 
  
 Dec 
 
 
 
 
 
In what year were 
you born? 
 
 
19 |___|___| 
0 
0 
1 
1 
2 
2 
3 
3 
4 
4 
5 
5 
6 
6 
7 
7 
8 
8 
9 
9 
 
 
 
 
 
Are you male or 
female? 
 
 
Male 
 
Female 
GENERAL INSTRUCTIONS 
 
Answer each question as best you can.  Estimate if you are not sure.  A guess is 
better than leaving a blank. 
 
Use only a black ball-point pen.  Do not use a pencil or felt-tip pen.  Do not fold, 
staple, or tear the pages. 
 
Put an X in the box next to your answer.  
 
If you make any changes, cross out the incorrect answer and put an X in the box 
next to the correct answer.  Also draw a circle around the correct answer. 
 
If you mark NEVER, NO, or DON’T KNOW for a question, please follow any 
arrows or instructions that direct you to the next question. 
 
BEFORE TURNING THE PAGE, PLEASE COMPLETE THE FOLLOWING QUESTIONS. 
BAR CODE LABEL OR SUBJECT ID 
HERE  
 
|___|___|___|___|___|___|___|___| 
DHQ II PastMonth  


This is a sample form.  Do not use for scanning. 
 
2 
 
1. Over the past month, how often did you drink 
carrot juice? 
 
 NEVER (GO TO QUESTION 2) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
1a. 
Each time you drank carrot juice, how 
much did you usually drink? 
 
 Less than ½ cup (4 ounces) 
 ½ to 1¼ cups (4 to 10 ounces) 
 More than 1¼ cups (10 ounces) 
 
2.  Over the past month, how often did you drink 
tomato juice or other vegetable juice? 
 
(Please do not include carrot juice.) 
 
 NEVER (GO TO QUESTION 3) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
2a. 
Each time you drank tomato juice or other 
vegetable juice, how much did you usually 
drink? 
 
 Less than ¾ cup (6 ounces) 
 ¾ to 1¼ cups (6 to 10 ounces) 
 More than 1¼ cups (10 ounces) 
 
3. 
Over the past month, how often did you drink 
orange juice or grapefruit juice? 
 
 NEVER (GO TO QUESTION 4) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
3a. 
Each time you drank orange juice or 
grapefruit juice, how much did you usually 
drink? 
 
 Less than ¾ cup (6 ounces) 
 ¾ to 1¼ cups (6 to 10 ounces) 
 More than 1¼ cups (10 ounces) 
 
 
3b.  
How often was the orange juice or grapefruit 
juice you drank calcium-fortified? 
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
 
  
 Almost always or always 
 
4. 
Over the past month, how often did you drink 
other 100% fruit juice or 100% fruit juice 
mixtures (such as apple, grape, pineapple, or 
others)? 
 
 NEVER (GO TO QUESTION 5) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
4a. 
Each time you drank other 100% fruit juice 
or 100% fruit juice mixtures, how much did 
you usually drink? 
 
 Less than ¾ cup (6 ounces) 
 ¾ to 1½ cups (6 to 12 ounces) 
 More than 1½ cups (12 ounces) 
  
4b.  
How often were the other 100% fruit juice or 
100% fruit juice mixtures you drank 
calcium-fortified? 
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
 
 Almost always or always 
 
5. 
How often did you drink other fruit drinks (such 
as cranberry cocktail, Hi-C, lemonade, or Kool-
Aid, diet or regular)? 
 
 NEVER (GO TO QUESTION 6) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
 
Question 4 appears in the next column 
Question 6 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
3 
Over the past month… 
 
5a. 
Each time you drank fruit drinks, how much 
did you usually drink? 
 
 Less than 1 cup (8 ounces) 
 1 to 2 cups (8 to 16 ounces) 
 More than 2 cups (16 ounces) 
 
5b. 
How often were your fruit drinks diet or 
sugar-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
6. 
How often did you drink milk as a beverage 
(NOT in coffee, NOT in cereal)?  (Please do not 
include chocolate milk and hot chocolate.) 
 
 NEVER (GO TO QUESTION 7) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
6a. 
Each time you drank milk as a beverage, 
how much did you usually drink? 
 
 Less than 1 cup (8 ounces) 
 1 to 1½ cups (8 to 12 ounces) 
 More than 1½ cups (12 ounces)  
 
6b. 
What kind of milk did you usually drink? 
 
 Whole milk 
 2% fat milk 
 1 % fat milk 
 Skim, nonfat, or ½% fat milk 
 Soy milk 
 Rice milk 
 Other 
 
7. 
How often did you drink chocolate milk 
(including hot chocolate)?  
 
 NEVER (GO TO QUESTION 8) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
7a.  
Each time you drank chocolate milk, how 
much did you usually drink? 
 
 Less than 1 cup (8 ounces) 
 1 to 1½ cups (8 to 12 ounces) 
 More than 1½ cups (12 ounces)  
 
 
7b.  
How often was the chocolate milk reduced- 
fat or fat-free? 
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
 
 Almost always or always 
 
8. 
How often did you drink meal replacement or 
high-protein beverages (such as Instant 
Breakfast, Ensure, Slimfast, Sustacal or others)? 
 
 NEVER (GO TO QUESTION 9) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
8a. 
Each time you drank meal replacement or 
high-protein beverages, how much did you 
usually drink? 
 
 Less than 1 cup (8 ounces) 
 1 to 1½ cups (8 to 12 ounces) 
 More than 1½ cups (12 ounces)  
 
9. 
How often did you drink soda or pop? 
 
 NEVER (GO TO QUESTION 10) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
9a. 
Each time you drank soda or pop, how 
much did you usually drink? 
 
 Less than 12 ounces or less than 1 can or bottle 
 12 to 16 ounces or 1 can or bottle 
 More than 16 ounces or more than 1 can or bottle 
 
Question 8 appears in the next column 
Question 10 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
4 
Over the past month… 
 
9b. 
How often were these sodas or pop diet or 
sugar-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
9c. 
How often were these sodas or pop 
caffeine-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
10.  How often did you drink sports drinks (such as 
Propel, PowerAde, or Gatorade)?  
 
 NEVER (GO TO QUESTION 11) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
10a. Each time you drank sports drinks, how 
much did you usually drink? 
 
 Less than 12 ounces or less than 1 bottle 
 12 to 24 ounces or 1 to 2 bottles 
 More than 24 ounces or more than 2 bottles 
 
11.  How often did you drink energy drinks (such as 
Red Bull or Jolt)?  
 
 NEVER (GO TO QUESTION 12) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
11a. Each time you drank energy drinks, how 
much did you usually drink? 
 
 Less than 8 ounces or less than 1 cup 
 8 to 16 ounces or 1 to 2 cups 
 More than 16 ounces or more than 2 cups 
 
 
12. How often did you drink beer? 
 
 NEVER (GO TO QUESTION 13) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
12a. Each time you drank beer, how much did 
you usually drink? 
 
 Less than a 12-ounce can or bottle 
 1 to 3 12-ounce cans or bottles 
 More than 3 12-ounce cans or bottles 
 
                         
 
 
13.  How often did you drink water (including tap, 
bottled, and carbonated water)?  
 
 NEVER (GO TO QUESTION 14) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
13a.  Each time you drank water, how much did 
you usually drink? 
 
 Less than 12 ounces or less than 1 bottle 
 12 to 24 ounces or 1 to 2 bottles 
 More than 24 ounces or more than 2 bottles 
 
13b.  How often was the water you drank tap 
water? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
Question 12 appears in the next column 
Question 14 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
5 
Over the past month… 
 
13c.  How often was the water you drank bottled, 
sweetened water (with low or no-calorie 
sweetener, including carbonated water)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
13d.  How often was the water you drank bottled, 
unsweetened water (including carbonated 
water)? 
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
 
  
 Almost always or always  
 
14. How often did you drink wine or wine coolers? 
 
 NEVER (GO TO QUESTION 15) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
14a. Each time you drank wine or wine coolers, 
how much did you usually drink? 
  
 Less than 5 ounces or less than 1 glass 
 5 to 12 ounces or 1 to 2 glasses 
 More than 12 ounces or more than 2 glasses 
 
15. How often did you drink liquor or mixed 
drinks? 
 
 NEVER (GO TO QUESTION 16) 
 
 1 time in past month 
 1 time per day 
 2–3 times in past month 
 2–3 times per day 
 1–2 times per week 
 4–5 times per day 
 3–4 times per week 
 6 or more times per day 
 5–6 times per week 
 
 
15a. Each time you drank liquor or mixed 
drinks, how much did you usually drink? 
 
 Less than 1 shot of liquor 
 1 to 3 shots of liquor 
 More than 3 shots of liquor 
 
 
16. How often did you eat oatmeal, grits, or other 
cooked cereal? 
 
 NEVER (GO TO QUESTION 17) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
16a. Each time you ate oatmeal, grits, or other 
cooked cereal, how much did you usually 
eat? 
 
 Less than ¾ cup  
 ¾ to 1¼ cups  
 More than 1¼ cups  
 
16b.  How often was butter or margarine added 
to your oatmeal, grits or other cooked 
cereal?  
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
 
 Almost always or always 
 
17. How often did you eat cold cereal? 
 
 NEVER (GO TO QUESTION 18) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
17a. Each time you ate cold cereal, how much 
did you usually eat? 
 
 Less than 1 cup 
 1 to 2½ cups 
 More than 2½ cups 
 
17b. How often was the cold cereal you ate Total 
Raisin Bran, Total Cereal, or Product 19?  
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
Question 16 appears in the next column 
Question 18 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
6 
Over the past month… 
 
17c. How often was the cold cereal you ate All 
Bran, Fiber One, 100% Bran, or All-Bran 
Bran Buds? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
17d. How often was the cold cereal you ate some 
other bran or fiber cereal (such as Cheerios, 
Shredded Wheat, Raisin Bran, Bran Flakes, 
Grape-Nuts, Granola, Wheaties, or Healthy 
Choice)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
17e. How often was the cold cereal you ate any 
other type of cold cereal (such as Corn 
Flakes, Rice Krispies, Frosted Flakes, Special 
K, Froot Loops, Cap'n Crunch, or others)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
17f. 
Was milk added to your cold cereal? 
 
 NO (GO TO QUESTION 18) 
 
 YES 
 
17g. What kind of milk was usually added? 
 
 Whole milk 
 2% fat milk 
 1% fat milk 
 Skim, nonfat, or ½% fat milk 
 Soy milk 
 Rice milk 
 Other 
 
17h. Each time milk was added to your cold 
cereal, how much was usually added? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
 
18. How often did you eat applesauce? 
 
 NEVER (GO TO QUESTION 19) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
18a. Each time you ate applesauce, how much 
did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
19. How often did you eat apples? 
 
 NEVER (GO TO QUESTION 20) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
19a. Each time you ate apples, how many did 
you usually eat? 
 
 Less than 1 apple 
 1 apple 
 More than 1 apple 
 
20. How often did you eat pears (fresh, canned, or 
frozen)? 
 
 NEVER (GO TO QUESTION 21) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
20a. Each time you ate pears, how many did you 
usually eat? 
 
 Less than 1 pear 
 1 pear 
 More than 1 pear 
 
21. How often did you eat bananas? 
 
 NEVER (GO TO QUESTION 22) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
Question 22 appears on the next page 
Question 18 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
7 
Over the past month… 
 
21a. Each time you ate bananas, how many did 
you usually eat? 
 
 Less than 1 banana 
 1 banana 
 More than 1 banana  
 
 
 
22. How often did you eat dried fruit (such as 
prunes or raisins)? (Please do not include dried 
apricots.) 
 
 NEVER (GO TO QUESTION 23) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
22a. Each time you ate dried fruit, how much did 
you usually eat? 
 
 Less than 2 tablespoons 
 2 to 5 tablespoons 
 More than 5 tablespoons 
 
23. How often did you eat peaches, nectarines, or 
plums? 
 
 NEVER (GO TO QUESTION 24) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
23a. Each time you ate peaches, nectarines, or 
plums, how much did you usually eat? 
 
 Less than 1 fruit or less than ½ cup 
 1 to 2 fruits or ½ to ¾ cup 
 More than 2 fruits or more than ¾ cup 
 
24. How often did you eat grapes? 
 
  NEVER (GO TO QUESTION 25) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
24a. Each time you ate grapes, how much did 
you usually eat? 
 
 Less than ½ cup or less than 10 grapes 
 ½ to 1 cup or 10 to 30 grapes 
 More than 1 cup or more than 30 grapes 
 
25. How often did you eat cantaloupe? 
 
 NEVER (GO TO QUESTION 26) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
25a. Each time you ate cantaloupe, how much 
did you usually eat? 
 
 Less than ¼ melon or less than ½ cup 
 ¼ melon or ½ to 1 cup 
 More than ¼ melon or more than 1 cup  
 
26. How often did you eat melon, other than 
cantaloupe (such as watermelon or 
honeydew)? 
 
 NEVER (GO TO QUESTION 27) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
26a. Each time you ate melon other than 
cantaloupe, how much did you usually eat? 
 
 Less than ½ cup or 1 small wedge 
 ½ to 2 cups or 1 medium wedge 
 More than 2 cups or 1 large wedge 
 
 
 
 
 
 
Question 24 appears in the next column 
Question 27 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
8 
Over the past month… 
 
27. How often did you eat strawberries? 
 
 NEVER (GO TO QUESTION 28) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
27a. Each time you ate strawberries, how much 
did you usually eat? 
 
 Less than ¼ cup or less than 3 berries 
 ¼ to ¾ cup or 3 to 8 berries 
 More than ¾ cup or more than 8 berries 
 
28. How often did you eat oranges, tangerines, or 
clementines? 
 
 NEVER (GO TO QUESTION 29) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
28a. Each time you ate oranges, tangerines, or 
clementines, how many did you usually 
eat? 
 
 Less than 1 fruit 
 1 fruit 
 More than 1 fruit 
 
29. How often did you eat grapefruit? 
 
 NEVER (GO TO QUESTION 30) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
29a. Each time you ate grapefruit, how much did 
you usually eat? 
 
 Less than ½ grapefruit 
 ½ grapefruit 
 More than ½ grapefruit 
 
30. How often did you eat pineapple?  
 
  NEVER (GO TO QUESTION 31) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
30a. Each time you ate pineapple, how much did 
you usually eat? 
 
 Less than ¼ cup or less than 1 medium slice 
 ¼ to ¾ cup or 1 medium slice 
 More than ¾ cup or more than 1 medium slice 
 
31. How often did you eat other kinds of fruit? 
 
 NEVER (GO TO QUESTION 32) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
31a. Each time you ate other kinds of fruit, how 
much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to ¾ cup 
 More than ¾ cup 
 
32. How often did you eat COOKED greens (such 
as spinach, turnip, collard, mustard, chard, or 
kale)? 
 
 NEVER (GO TO QUESTION 33) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
32a. Each time you ate COOKED greens, how 
much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
33. How often did you eat RAW greens (such as 
spinach, turnip, collard, mustard, chard, or 
kale)?  (We will ask about lettuce later.) 
 
 NEVER (GO TO QUESTION 34) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
Question 30 appears in the next column 
Question 34 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
9 
Over the past month… 
 
33a. Each time you ate RAW greens, how much 
did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
34. How often did you eat coleslaw? 
 
 NEVER (GO TO QUESTION 35) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
34a. Each time you ate coleslaw, how much did 
you usually eat? 
 
 Less than ¼ cup 
 ¼ to ¾ cup 
 More than ¾ cup 
 
35. How often did you eat sauerkraut or cabbage 
(other than coleslaw)? 
 
 NEVER (GO TO QUESTION 36) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
35a. Each time you ate sauerkraut or cabbage, 
how much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to 1 cup 
 More than 1 cup 
 
36. How often did you eat carrots (fresh, canned, or 
frozen)? 
 
 NEVER (GO TO QUESTION 37) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
36a. Each time you ate carrots, how much did 
you usually eat? 
 
 Less than ¼ cup or less than 2 baby carrots 
 ¼ to ½ cup or 2 to 5 baby carrots 
 More than ½ cup or more than 5 baby carrots 
 
37. How often did you eat string beans or green 
beans (fresh, canned, or frozen)? 
 
 NEVER (GO TO QUESTION 38) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
37a. Each time you ate string beans or green 
beans, how much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
38. How often did you eat peas (fresh, canned, or 
frozen)? 
 
 NEVER (GO TO QUESTION 39) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
38a. Each time you ate peas, how much did you 
usually eat? 
 
 Less than ¼ cup 
 ¼ to ¾ cup 
 More than ¾ cup 
 
39. How often did you eat corn? 
 
 NEVER (GO TO QUESTION 40) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 
39a. Each time you ate corn, how much did you 
usually eat? 
 
 Less than 1 ear or less than ½ cup 
 1 ear or ½ to 1 cup 
 More than 1 ear or more than 1 cup 
 
 
 
 
 
Question 40 appears on the next page 
Question 37 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
10 
Over the past month… 
 
40. How often did you eat broccoli (fresh or 
frozen)? 
 
 NEVER (GO TO QUESTION 41) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
40a. Each time you ate broccoli, how much did 
you usually eat? 
 
 Less than ¼ cup 
 ¼ to 1 cup 
 More than 1 cup 
 
41. How often did you eat cauliflower or Brussels 
sprouts (fresh or frozen)? 
 
 NEVER (GO TO QUESTION 42) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
41a. Each time you ate cauliflower or Brussels 
sprouts, how much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to ½ cup 
 More than ½ cup 
 
42. How often did you eat asparagus (fresh or 
frozen)? 
 
 NEVER (GO TO QUESTION 43) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
42a. Each time you ate asparagus, how much 
did you usually eat? 
 
 Less than ⅓ cup or less than 4 spears 
 ⅓ to ⅔ cup or 4 to 7 spears 
 More than ⅔ cup or more than 7 spears 
 
 
 
43.  How often did you eat winter squash (such as 
pumpkin, butternut, or acorn)? 
 
  NEVER (GO TO QUESTION 44) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
43a. Each time you ate winter squash, how 
much did you usually eat? 
 
 Less than ½ cup 
 ½ to ¾ cup 
 More than ¾ cup 
 
44. How often did you eat mixed vegetables? 
 
 NEVER (GO TO QUESTION 45) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
44a. Each time you ate mixed vegetables, how 
much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
45. How often did you eat onions? 
 
 NEVER (GO TO QUESTION 46) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
45a. Each time you ate onions, how much did 
you usually eat? 
 
 Less than 1 slice or less than 1 tablespoon 
 1 slice or 1 to 4 tablespoons 
 More than 1 slice or more than 4 tablespoons 
 
 
Question 46 appears on the next page 
Question 43 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
11 
Over the past month… 
 
46. Now think about all the cooked vegetables you 
ate in the past month and how they were 
prepared.  How often were your vegetables 
COOKED WITH some sort of fat, including oil 
spray?  (Please do not include potatoes.) 
 
 NEVER (GO TO QUESTION 47) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
                             
 
 
46a. Which fats were usually added to your 
vegetables DURING COOKING?  (Please 
do not include potatoes.  Mark all that 
apply.) 
 
 Margarine 
(including low-fat) 
 Corn oil 
 Canola or rapeseed oil 
 Butter (including 
low-fat) 
 Oil spray, such as Pam 
or others 
 Lard, fatback, or 
bacon fat 
 Other kinds of oils 
 None of the above 
 Olive oil 
 
 
47. Now, thinking again about all the cooked 
vegetables you ate in the past month, how often 
was some sort of fat, sauce, or dressing added 
AFTER COOKING OR AT THE TABLE?  
(Please do not include potatoes.) 
 
 NEVER (GO TO QUESTION 48) 
 
 1 time in past month 
 5–6 times per week 
 2–3 times in past month 
 1 time per day  
 1–2 times per week 
  2 times per day 
 3–4 times per week 
  3 or more times per day 
 
 
47a. Which fats, sauces, or dressings were 
usually added AFTER COOKING OR AT 
THE TABLE?  (Please do not include 
potatoes.  Mark all that apply.) 
 
 Margarine 
(including low-fat) 
 Salad dressing 
 Cheese sauce 
 Butter (including 
low-fat) 
 White sauce 
 Other 
 Lard, fatback, or 
bacon fat 
 
 
47b. If margarine, butter, lard, fatback, or bacon 
fat was added to your cooked vegetables 
AFTER COOKING OR AT THE TABLE, 
how much did you usually add? 
 
 Did not usually add these 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
47c. If salad dressing, cheese sauce, or white 
sauce was added to your cooked vegetables 
AFTER COOKING OR AT THE TABLE, 
how much did you usually add? 
 
 Did not usually add these 
 Less than 1 tablespoon 
 1 to 3 tablespoons 
 More than 3 tablespoons 
 
48. How often did you eat sweet peppers (green, 
red, or yellow)? 
 
 NEVER (GO TO QUESTION 49) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
48a. Each time you ate sweet peppers, how 
much did you usually eat? 
 
 Less than ⅛ pepper 
 ⅛ to ¼ pepper 
 More than ¼ pepper 
 
Question 48 appears in the next column 
Question 49 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
12 
Over the past month… 
 
49. How often did you eat fresh tomatoes 
(including those in salads)? 
 
 NEVER (GO TO QUESTION 50) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
49a. Each time you ate fresh tomatoes, how 
much did you usually eat? 
 
 Less than ¼ tomato 
 ¼ to ½ tomato 
 More than ½ tomato 
 
50. How often did you eat lettuce salads (with or 
without other vegetables)? 
 
 NEVER (GO TO QUESTION 51) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
50a.  Each time you ate lettuce salads, how 
much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to 1¼ cups  
 More than 1¼ cups 
 
50b. How often did the lettuce salads you ate 
include dark green lettuce? 
 
 
 Almost never or never  
 
 About ¼ of the time 
 
 About ½ of the time 
 
 About ¾ of the time 
      
 Almost always or always  
 
51. How often did you eat salad dressing (including 
low-fat) on salads? 
 
 NEVER (GO TO QUESTION 52) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
51a. Each time you ate salad dressing on 
salads, how much did you usually eat? 
 
 Less than 2 tablespoons 
 2 to 4 tablespoons 
 More than 4 tablespoons 
52. How often did you eat sweet potatoes or 
yams? 
 
 NEVER (GO TO QUESTION 53) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
52a. Each time you ate sweet potatoes or yams, 
how much did you usually eat? 
 
 1 small potato or less than ¼ cup 
 1 medium potato or ¼ to ¾ cup 
 1 large potato or more than ¾ cup 
 
53. How often did you eat French fries, home fries, 
hash browned potatoes, or tater tots? 
 
 NEVER (GO TO QUESTION 54) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
53a. Each time you ate French fries, home 
fries, hash browned potatoes, or tater 
tots how much did you usually eat? 
 
 Less than 10 fries or less than ½ cup 
 10 to 25 fries or ½ to 1 cup 
 More than 25 fries or more than 1 cup 
 
54. How often did you eat potato salad? 
 
 NEVER (GO TO QUESTION 55) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
54a. Each time you ate potato salad, how much 
did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
55. How often did you eat baked, boiled, or 
mashed potatoes? 
 
 NEVER (GO TO QUESTION 56) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
Question 52 appears in the next column 
Question 56 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
13 
Over the past month… 
 
55a. Each time you ate baked, boiled, or 
mashed potatoes, how much did you 
usually eat? 
 
 1 small potato or less than ½ cup 
 1 medium potato or ½ to 1 cup 
 1 large potato or more than 1 cup 
 
55b. How often was sour cream (including low-
fat) added to your potatoes, EITHER IN 
COOKING OR AT THE TABLE? 
 
 Almost never or never (GO TO QUESTION 55d) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
55c. Each time sour cream was added to your 
potatoes, how much was usually added? 
 
 Less than 1 tablespoon 
 1 to 3 tablespoons 
 More than 3 tablespoons 
 
55d. How often was margarine (including low-fat) 
added to your potatoes, EITHER IN COOKING 
OR AT THE TABLE? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
55e. How often was butter (including low-fat) added 
to your potatoes, EITHER IN COOKING OR AT 
THE TABLE? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
55f. 
Each time margarine or butter was added 
to your potatoes, how much was usually 
added? 
 
 Never added 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
55g. How often was cheese or cheese sauce added 
to your potatoes, EITHER IN COOKING OR AT 
THE TABLE? 
 
 Almost never or never (GO TO QUESTION 56) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
55h. Each time cheese or cheese sauce was 
added to your potatoes, how much was 
usually added? 
 
 Less than 1 tablespoon 
 1 to 3 tablespoons 
 More than 3 tablespoons 
 
56. How often did you eat salsa? 
 
 NEVER (GO TO QUESTION 57) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
56a. Each time you ate salsa, how much did you 
usually eat? 
 
 Less than 1 tablespoon 
 1 to 5 tablespoons 
 More than 5 tablespoons 
 
57. How often did you eat catsup? 
 
 NEVER (GO TO QUESTION 58) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
57a. Each time you ate catsup, how much did 
you usually eat? 
 
 Less than 1 teaspoon 
 1 to 6 teaspoons 
 More than 6 teaspoons 
 
58. How often did you eat stuffing, dressing, or 
dumplings? 
 
 NEVER (GO TO QUESTION 59) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
Question 59 appears on the next page 
Question 56 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
14 
Over the past month… 
 
58a. Each time you ate stuffing, dressing, or 
dumplings, how much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
  
59. How often did you eat chili? 
 
 NEVER (GO TO QUESTION 60) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
59a. Each time you ate chili, how much did you 
usually eat? 
 
 Less than ½ cup 
 ½ to 1¾ cups 
 More than 1¾ cups 
 
60. How often did you eat Mexican foods (such as 
tacos, tostados, burritos, tamales, fajitas, 
enchiladas, quesadillas, and chimichangas)? 
 
 NEVER (GO TO QUESTION 61) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
60a. Each time you ate Mexican foods, how 
much did you usually eat? 
 
 Less than 1 taco, burrito, etc. 
 1 to 2 tacos, burritos, etc. 
 More than 2 tacos, burritos, etc. 
 
61. How often did you eat cooked dried beans 
(such as baked beans, pintos, kidney, blackeyed 
peas, lima, lentils, soybeans, or refried beans)?  
(Please do not include bean soups or chili.) 
 
 NEVER (GO TO QUESTION 62) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
61a. Each time you ate beans, how much did you 
usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
61b. How often were the beans you ate refried 
beans, beans prepared with any type of 
fat, or with meat added? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
62. How often did you eat other kinds of 
vegetables? 
 
 NEVER (GO TO QUESTION 63) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
62a. Each time you ate other kinds of 
vegetables, how much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to ½ cup 
 More than ½ cup 
 
63. How often did you eat rice or other cooked 
grains (such as bulgur, cracked wheat, or 
millet)? 
 
 NEVER (GO TO QUESTION 64) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
63a. Each time you ate rice or other cooked 
grains, how much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1½ cups 
 More than 1½ cups 
 
63b. How often was butter, margarine, or oil 
added to your rice or other cooked grains IN 
COOKING OR AT THE TABLE? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
 
Question 64 appears on the next page 
Question 62 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
15 
Over the past month… 
 
64. How often did you eat pancakes, waffles, or 
French toast? 
 
 NEVER (GO TO QUESTION 65) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
64a. Each time you ate pancakes, waffles, or 
French toast, how much did you usually eat? 
 
 Less than 1 medium piece 
 1 to 3 medium pieces 
 More than 3 medium pieces 
 
64b. How often was margarine (including low-fat) 
added to your pancakes, waffles, or French 
toast AFTER COOKING OR AT THE TABLE? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
64c. How often was butter (including low-fat) 
added to your pancakes, waffles, or French 
toast AFTER COOKING OR AT THE TABLE? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
64d. Each time margarine or butter was added to 
your pancakes, waffles, or French toast, how 
much was usually added? 
 
 Never added 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
64e. How often was syrup added to your pancakes, 
waffles, or French toast? 
 
 Almost never or never (GO TO QUESTION 65) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
64f. 
Each time syrup was added to your pancakes, 
waffles, or French toast, how much was 
usually added? 
 
 Less than 1 tablespoon 
 1 to 4 tablespoons 
 More than 4 tablespoons 
 
65. How often did you eat lasagna, stuffed shells, 
stuffed manicotti, ravioli, or tortellini?  
(Please do not include spaghetti or other pasta.) 
 
 NEVER (GO TO QUESTION 66) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
65a. Each time you ate lasagna, stuffed shells, 
stuffed manicotti, ravioli, or tortellini, how 
much did you usually eat? 
 
 Less than 1 cup 
 1 to 2 cups 
 More than 2 cups 
 
66. How often did you eat macaroni and cheese? 
 
 NEVER (GO TO QUESTION 67) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
66a. Each time you ate macaroni and cheese, 
how much did you usually eat? 
 
 Less than 1 cup 
 1 to 1½ cups 
 More than 1½ cups 
 
67. How often did you eat pasta salad or macaroni 
salad? 
 
 NEVER (GO TO QUESTION 68) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 
Question 65 appears in the next column 
Question 68 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
16 
Over the past month… 
 
67a. Each time you ate pasta salad or macaroni 
salad, how much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
68. Other than the pastas listed in Questions 65, 66, 
and 67, how often did you eat pasta, spaghetti, 
or other noodles? 
 
 NEVER (GO TO QUESTION 69) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
68a. Each time you ate pasta, spaghetti, or 
other noodles, how much did you usually 
eat? 
 
 Less than 1 cup 
 1 to 3 cups 
 More than 3 cups 
 
68b. How often did you eat your pasta, spaghetti, 
or other noodles with tomato sauce or 
spaghetti sauce made WITH meat? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
68c. How often did you eat your pasta, spaghetti, 
or other noodles with tomato sauce or 
spaghetti sauce made WITHOUT meat? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
68d. How often did you eat your pasta, spaghetti, 
or other noodles with margarine, butter, oil, 
or cream sauce? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
69. How often did you eat bagels or English 
muffins? 
 
 NEVER (GO TO INTRODUCTION TO QUESTION 70) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
69a.  How often were the bagels or English 
muffins you ate whole wheat? 
 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
69b. Each time you ate bagels or English 
muffins, how many did you usually eat? 
 
 Less than 1 bagel or English muffin 
 1 bagel or English muffin 
 More than 1 bagel or English muffin 
 
69c. How often was margarine (including low-fat) 
added to your bagels or English muffins? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
69d. How often was butter (including low-fat) 
added to your bagels or English muffins? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
69e. Each time margarine or butter was added 
to your bagels or English muffins, how much 
was usually added? 
 
 Never added 
 Less than 1 teaspoon 
 1 to 2 teaspoons 
 More than 2 teaspoons 
 
Question 69 appears in the next column 
Introduction to Question 70 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
17 
Over the past month… 
 
69f. How often was cream cheese (including low-fat) 
spread on your bagels or English muffins? 
 
 Almost never or never (GO TO INTRODUCTION 
TO QUESTION 70) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
69g. Each time cream cheese was added to your 
bagels or English muffins, how much was 
usually added? 
 
 Less than 1 tablespoon 
 1 to 2 tablespoons 
 More than 2 tablespoons 
 
 
The next questions ask about your intake of 
breads other than bagels or English muffins.  First, 
we will ask about bread you ate as part of 
sandwiches only.  Then we will ask about all other 
bread you ate. 
 
70. How often did you eat breads or rolls AS PART 
OF SANDWICHES (including burger and hot 
dog rolls)?  
 
(Please do not include fast food sandwiches.) 
 
 NEVER (GO TO QUESTION 71) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
70a. Each time you ate breads or rolls AS PART 
OF SANDWICHES, how many did you 
usually eat? 
 
 1 slice or ½ roll 
 2 slices or 1 roll 
 More than 2 slices or more than 1 roll 
 
70b. How often were the breads or rolls that you 
used for your sandwiches white bread 
(including burger and hot dog rolls)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
70c. How often was mayonnaise or 
mayonnaise-type dressing (including low-
fat) added to the breads or rolls used for 
your sandwiches? 
 
 Almost never or never (GO TO QUESTION 70e) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
70d. Each time mayonnaise or mayonnaise-type 
dressing was added to the breads or rolls 
used for your sandwiches, how much was 
usually added? 
 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
70e. How often was margarine (including low-fat) 
added to the breads or rolls used for your 
sandwiches? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
70f. 
How often was butter (including low-fat) 
added to the breads or rolls used for your 
sandwiches? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
70g. Each time margarine or butter was added 
to the breads or rolls used for your 
sandwiches, how much was usually added? 
 
 Never added 
 Less than 1 teaspoon 
 1 to 2 teaspoons 
 More than 2 teaspoons 
 
71. How often did you eat breads or dinner rolls, 
NOT AS PART OF SANDWICHES? 
 
 NEVER (GO TO QUESTION 72) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
Question 71 appears in the next column 
Question 72 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
18 
Over the past month… 
 
71a. Each time you ate breads or dinner rolls, 
NOT AS PART OF SANDWICHES, how 
much did you usually eat? 
 
 1 slice or 1 dinner roll 
 2 slices or 2 dinner rolls 
 More than 2 slices or 2 dinner rolls 
 
71b. How often were the breads or rolls you ate 
white bread? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
71c. How often was margarine (including low-fat) 
added to your breads or rolls? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
71d. How often was butter (including low-fat) 
added to your breads or rolls? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
71e. Each time margarine or butter was added 
to your breads or rolls, how much was 
usually added? 
 
 Never added 
 Less than 1 teaspoon 
 1 to 2 teaspoons 
 More than 2 teaspoons 
 
71f. 
How often was cream cheese (including 
low-fat) added to your breads or rolls? 
 
 Almost never or never (GO TO QUESTION 72) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
71g. Each time cream cheese was added to your 
breads or rolls, how much was usually added? 
 
 Less than 1 tablespoon 
 1 to 2 tablespoons 
 More than 2 tablespoons 
         
72. How often did you eat jam, jelly, or honey on 
bagels, muffins, bread, rolls, or crackers? 
 
 NEVER (GO TO QUESTION 73) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
72a. Each time you ate jam, jelly, or honey, how 
much did you usually eat? 
 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
73. How often did you eat peanut butter or other 
nut butter? 
 
 NEVER (GO TO QUESTION 74) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
73a. Each time you ate peanut butter or other 
nut butter, how much did you usually eat? 
 
 Less than 1 tablespoon 
 1 to 2 tablespoons 
 More than 2 tablespoons 
 
74. How often did you eat roast beef or steak IN 
SANDWICHES? 
 
 NEVER (GO TO QUESTION 75) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
74a. Each time you ate roast beef or steak IN 
SANDWICHES, how much did you usually eat? 
 
 Less than 1 slice or less than 2 ounces 
 1 to 2 slices or 2 to 4 ounces 
 More than 2 slices or more than 4 ounces 
 
Question 72 appears in the next column 
Question 75 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
19 
Over the past month… 
 
75. How often did you eat turkey or chicken COLD 
CUTS (such as loaf, luncheon meat, turkey ham, 
turkey salami, or turkey pastrami)?  (We will ask 
about other turkey or chicken later.) 
 
 NEVER (GO TO QUESTION 76) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
75a. Each time you ate turkey or chicken COLD 
CUTS, how much did you usually eat? 
 
 Less than 1 slice 
 1 to 3 slices  
 More than 3 slices  
 
76. How often did you eat luncheon or deli-style 
ham?  (We will ask about other ham later.) 
 
 NEVER (GO TO QUESTION 77) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
76a. Each time you ate luncheon or deli-style 
ham, how much did you usually eat? 
 
 Less than 1 slice  
 1 to 3 slices  
 More than 3 slices  
 
76b. How often was the luncheon or deli-style 
ham you ate light, low-fat, or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
77. How often did you eat other cold cuts or 
luncheon meats (such as bologna, salami, 
corned beef, pastrami, or others, including low-
fat)?  (Please do not include ham, turkey, or 
chicken cold cuts.) 
 
 NEVER (GO TO QUESTION 78) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
77a. Each time you ate other cold cuts or 
luncheon meats, how much did you usually 
eat? 
 
 Less than 1 slice 
 1 to 3 slices 
 More than 3 slices 
 
77b. How often were the other cold cuts or luncheon 
meats you ate light, low-fat, or fat-free?  
(Please do not include ham, turkey, or chicken 
cold cuts.)  
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
78. How often did you eat canned tuna (including in 
salads, sandwiches, or casseroles)? 
 
 NEVER (GO TO QUESTION 79) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
78a. Each time you ate canned tuna, how much 
did you usually eat? 
 
 Less than ¼ cup or less than 2 ounces 
 ¼ to ½ cup or 2 to 3 ounces 
 More than ½ cup or more than 3 ounces 
 
78b. How often was the canned tuna you ate 
water-packed? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
78c. How often was the canned tuna you ate 
prepared with mayonnaise or other 
dressing (including low-fat)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
 
Question 78 appears in the next column 
Question 79 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
20 
Over the past month… 
 
79. How often did you eat GROUND chicken or 
turkey?  (We will ask about other chicken and 
turkey later.) 
 
 NEVER (GO TO QUESTION 80) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 79a.  Each time you ate GROUND chicken or 
turkey, how much did you usually eat? 
 
 Less than 2 ounces or less than ½ cup  
 2 to 4 ounces or ½ to 1 cup 
 More than 4 ounces or more than 1 cup 
 
80.  How often did you eat beef hamburgers or 
cheeseburgers from a FAST FOOD or OTHER 
RESTAURANT? 
 
 NEVER (GO TO QUESTION 81) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
80a. Each time you ate beef hamburgers or 
cheeseburgers from a FAST FOOD or 
OTHER RESTAURANT, what size did you 
usually eat? 
 
 
 
 Small hamburger (such as a regular Burger 
King or McDonald‟s Hamburger) 
 Medium (such as McDonald‟s or Burger King 
Double Burger or Cheeseburger) 
 Large (such as Burger King Whopper or 
Double Whopper or a McDonald‟s Double 
Quarter Pounder) 
 
80b. Each time you ate beef hamburgers or 
cheeseburgers from a FAST FOOD or 
OTHER RESTAURANT, how much did you 
usually eat? 
 
 Less than 1 burger 
 1 burger 
 More than 1 burger 
 
80c.  How often did you have cheeseburgers 
rather than hamburgers? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
81. How often did you eat beef hamburgers or 
cheeseburgers that were NOT FROM A FAST 
FOOD or OTHER RESTAURANT? 
 
 NEVER (GO TO QUESTION 82) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
81a. Each time you ate beef hamburgers or 
cheeseburgers that were NOT FROM A 
FAST FOOD or OTHER RESTAURANT, 
how much did you usually eat? 
 
 Less than 1 patty or less than 2 ounces 
 1 patty or 2 to 4 ounces 
 More than 1 patty or more than 4 ounces 
 
81b. How often were these beef hamburgers or 
cheeseburgers made with lean ground 
beef? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
82. How often did you eat ground beef in mixtures 
(such as meatballs, casseroles, chili, or 
meatloaf)? 
 
 NEVER (GO TO QUESTION 83) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
82a. Each time you ate ground beef in 
mixtures, how much did you usually eat? 
 
 Less than 3 ounces or less than ½ cup  
 3 to 8 ounces or ½ to 1 cup  
 More than 8 ounces or more than 1 cup  
 
83. How often did you eat hot dogs or 
frankfurters?  (Please do not include sausages 
or vegetarian hot dogs.) 
 
 NEVER (GO TO QUESTION 84) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
Question 81 appears in the next column 
Question 84 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
21 
Over the past month… 
 
83a. Each time you ate hot dogs or frankfurters, 
how many did you usually eat? 
 
 Less than 1 hot dog 
 1 to 2 hot dogs 
 More than 2 hot dogs 
 
83b. How often were the hot dogs or frankfurters 
you ate light or low-fat? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
84. How often did you eat beef mixtures (such as 
beef stew, beef pot pie, beef and noodles, or 
beef and vegetables)? 
 
 NEVER (GO TO QUESTION 85) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
84a. Each time you ate beef mixtures, how 
much did you usually eat? 
 
 Less than 1 cup 
 1 to 2 cups 
 More than 2 cups 
 
85. How often did you eat roast beef or pot roast?  
(Please do not include roast beef or pot roast in 
sandwiches.) 
 
 NEVER (GO TO QUESTION 86) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
85a. Each time you ate roast beef or pot roast, 
how much did you usually eat? 
 
 Less than 2 ounces 
 2 to 5 ounces 
 More than 5 ounces  
 
86. How often did you eat steak (beef)?   
 
(Please do not include steak in sandwiches) 
 
 NEVER (GO TO QUESTION 87) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
86a. Each time you ate steak (beef), how much 
did you usually eat? 
 
 Less than 3 ounces 
 3 to 7 ounces 
 More than 7 ounces 
 
86b. How often was the steak you ate lean 
steak? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
87. How often did you eat pork or beef spareribs? 
 
 NEVER (GO TO QUESTION 88) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
87a. Each time you ate pork or beef spareribs, 
how much did you usually eat? 
 
 Less than 4 ribs 
 4 to 12 ribs 
 More than 12 ribs 
 
88. How often did you eat roast turkey, turkey 
cutlets, or turkey nuggets (including in 
sandwiches)? 
 
 NEVER (GO TO QUESTION 89) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
88a. Each time you ate roast turkey, turkey 
cutlets, or turkey nuggets, how much did 
you usually eat?  (Please note: 4 to 8 turkey 
nuggets = 3 ounces.) 
 
 Less than 2 ounces 
 2 to 4 ounces 
 More than 4 ounces 
Question 86 appears in the next column 
Question 89 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
22 
Over the past month… 
 
89. How often did you eat chicken mixtures (such 
as salads, sandwiches, casseroles, stews, or 
other mixtures)? 
 
 NEVER (GO TO QUESTION 90) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
89a. Each time you ate chicken mixtures, how 
much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1½ cups 
 More than 1½ cups 
 
90. How often did you eat baked, broiled, roasted, 
stewed, or fried chicken (including nuggets)?  
(Please do not include chicken in mixtures.) 
 
 NEVER (GO TO QUESTION 91) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
90a. Each time you ate baked, broiled, roasted, 
stewed, or fried chicken (including 
nuggets), how much did you usually eat? 
 
 Less than 2 drumsticks or wings, less than 
1 breast or thigh, or less than 4 nuggets 
 2 drumsticks or wings, 1 breast or thigh, or 4 to 
8 nuggets 
 More than 2 drumsticks or wings, more than 
1 breast or thigh, or more than 8 nuggets 
 
90b. How often was the chicken you ate fried 
chicken (including deep fried) or chicken 
nuggets? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
90c. How often was the chicken you ate WHITE 
meat? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
90d. How often did you eat chicken WITH skin? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
91. How often did you eat baked ham or ham 
steak? 
 
 NEVER (GO TO QUESTION 92) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
91a. Each time you ate baked ham or ham 
steak, how much did you usually eat? 
 
 Less than 1 ounce 
 1 to 3 ounces 
 More than 3 ounces 
 
92. How often did you eat pork (including chops, 
roasts, and in mixed dishes)?  (Please do not 
include ham, ham steak, or sausage.) 
 
 NEVER (GO TO QUESTION 93) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
92a. Each time you ate pork, how much did you 
usually eat? 
 
 Less than 2 ounces or less than 1 chop 
 2 to 5 ounces or 1 chop 
 More than 5 ounces or more than 1 chop 
 
93. How often did you eat gravy on meat, chicken, 
potatoes, rice, etc.? 
 
 NEVER (GO TO QUESTION 94) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
93a. Each time you ate gravy on meat, chicken, 
potatoes, rice, etc., how much did you 
usually eat? 
 
 Less than ⅛ cup 
 ⅛ to ½ cup 
 More than ½ cup 
 
Question 91 appears in the next column 
Question 94 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
23 
Over the past month… 
 
94. How often did you eat liver (all kinds) or 
liverwurst? 
 
 NEVER (GO TO QUESTION 95) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
94a. Each time you ate liver or liverwurst, how 
much did you usually eat? 
 
 Less than 1 ounce 
 1 to 4 ounces 
 More than 4 ounces 
 
95. How often did you eat bacon (including low-fat)? 
 
 NEVER (GO TO QUESTION 96) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
95a. Each time you ate bacon, how much did you 
usually eat? 
 
 Fewer than 2 slices 
 2 to 3 slices 
 More than 3 slices 
 
95b. How often was the bacon you ate light, low-
fat, or lean? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
96. How often did you eat sausage (including low-fat)? 
 
 NEVER (GO TO QUESTION 97) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
96a. Each time you ate sausage, how much did 
you usually eat? 
 
 Less than 1 patty or 2 links 
 1 to 3 patties or 2 to 5 links 
 More than 3 patties or 5 links 
 
96b. How often was the sausage you ate light, 
low-fat, or lean? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
97.  How often did you eat fried shellfish (such as 
crab, lobster, shrimp)? 
 
 NEVER (GO TO QUESTION 98) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
97a.  Each time you ate fried shellfish, how 
much did you usually eat? 
 
 Less than 2 ounces 
 2 to 4 ounces  
 More than 4 ounces 
 
98.  How often did you eat shellfish (such as crab, 
lobster, shrimp) that was NOT FRIED? 
 
 NEVER (GO TO QUESTION 99) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
98a.  Each time you ate shellfish that was NOT 
FRIED, how much did you usually eat? 
 
 Less than 1 ounce 
 1 to 4 ounces  
 More than 4 ounces 
 
99.  How often did you eat salmon, fresh tuna or 
trout? 
 
 NEVER (GO TO QUESTION 100) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
99a.  Each time you ate salmon, fresh tuna or 
trout, how much did you usually eat? 
 
 Less than 2 ounces 
 2 to 6 ounces  
 More than 6 ounces 
 
Question 97 appears in the next column 
Question 100 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
24 
Over the past month… 
 
100. How often did you eat fish sticks or other fried 
fish (not including shellfish)? 
 
 NEVER (GO TO QUESTION 101) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
100a. Each time you ate fish sticks or other fried 
fish, how much did you usually eat? 
 
 Less than 2 ounces or less than 1 fillet 
 2 to 7 ounces or 1 fillet 
 More than 7 ounces or more than 1 fillet 
 
101. How often did you eat other fish that was NOT 
FRIED (not including shellfish)? 
 
 NEVER (GO TO INTRODUCTION TO 
QUESTION 102) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
101a. Each time you ate other fish that was NOT 
FRIED, how much did you usually eat? 
 
 Less than 2 ounces or less than 1 fillet 
 2 to 5 ounces or 1 fillet 
 More than 5 ounces or more than 1 fillet 
 
Now think about all the meat, poultry, and fish 
you ate in the past month and how they were 
prepared. 
 
102. How often was oil, butter, margarine, or other 
fat used to FRY, SAUTE, BASTE, OR 
MARINATE any meat, poultry, or fish you ate?  
(Please do not include deep frying.) 
 
 NEVER (GO TO QUESTION 103) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
102a. Which of the following fats were regularly 
used to prepare your meat, poultry, or fish?  
(Mark all that apply.) 
 
 Margarine (including 
low-fat) 
 Corn oil 
 Canola or rapeseed oil 
 Butter (including 
low-fat) 
 Oil spray (such as Pam 
or others) 
 Lard, fatback, or 
bacon fat 
 Other kinds of oils 
 None of the above 
 Olive oil 
 
 
103. How often did you eat tofu, soy burgers, or 
soy meat-substitutes? 
 
 NEVER (GO TO QUESTION 104) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
103a. Each time you ate tofu, soy burgers, or 
soy meat-substitutes, how much did you 
usually eat? 
 
 
 Less than ¼ cup or less than 2 ounces 
 
 ¼ to ½ cup or 2 to 4 ounces 
 
 More than ½ cup or more than 4 ounces 
 
104. How often did you eat soups? 
 
 NEVER (GO TO QUESTION 105) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
104a. Each time you ate soup, how much did you 
usually eat? 
 
 Less than 1 cup 
 1 to 2 cups 
 More than 2 cups 
 
104b. How often were the soups you ate bean 
soups? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
 
 
Question 103 appears in the next column 
Question 105 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
25 
Over the past month… 
 
104c. How often were the soups you ate cream 
soups (including chowders)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
104d. How often were the soups you ate tomato 
or vegetable soups? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
104e.  How often were the soups you ate broth 
soups (including chicken) with or without 
noodles or rice? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
105. How often did you eat pizza? 
 
 NEVER (GO TO QUESTION 106) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
105a. Each time you ate pizza, how much did you 
usually eat? 
 
 Less than 1 slice or less than 1 mini pizza 
 1 to 3 slices or 1 mini pizza 
 More than 3 slices or more than 1 mini pizza 
 
105b. How often did you eat pizza with pepperoni, 
sausage, or other meat?  
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
106. How often did you eat crackers? 
 
 NEVER (GO TO QUESTION 107) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
106a. Each time you ate crackers, how many did 
you usually eat? 
 
 Fewer than 4 crackers 
 4 to 10 crackers 
 More than 10 crackers 
 
107. How often did you eat corn bread or corn 
muffins? 
 
 NEVER (GO TO QUESTION 108) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
107a. Each time you ate corn bread or corn 
muffins, how much did you usually eat? 
 
 Less than 1 piece or muffin 
 1 to 2 pieces or muffins 
 More than 2 pieces or muffins 
 
108. How often did you eat biscuits? 
 
 NEVER (GO TO QUESTION 109) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
108a. Each time you ate biscuits, how many did 
you usually eat? 
 
 Fewer than 1 biscuit 
 1 to 2 biscuits 
 More than 2 biscuits 
 
109. How often did you eat potato chips (including 
low-fat, fat-free, or low-salt)? 
 
 NEVER (GO TO QUESTION 110) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 
Question 106 appears in the next column 
Question 110 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
26 
Over the past month… 
 
109a. Each time you ate potato chips, how much 
did you usually eat? 
 
 Fewer than 10 chips or less than 1 cup 
 10 to 25 chips or 1 to 2 cups 
 More than 25 chips or more than 2 cups  
 
 
109b. How often were the potato chips you ate fat-
free? (Please do not include reduced-fat 
chips.) 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
110. How often did you eat corn chips or tortilla 
chips (including low-fat, fat-free, or low-salt)? 
 
 NEVER (GO TO QUESTION 111) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
110a.  Each time you ate corn chips, how much 
did you usually eat? 
 
 Fewer than 10 chips or less than 1 cup 
 10 to 25 chips or 1 to 1½ cups 
 More than 25 chips or more than 1½ cups  
 
110b.  How often were the corn chips or tortilla 
chips you ate fat-free? (Please do not 
include reduced-fat chips.) 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
111. How often did you eat popcorn (including low-
fat)? 
 
 NEVER (GO TO QUESTION 112) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 
111a. Each time you ate popcorn, how much did 
you usually eat? 
 
 Less than 2 cups, popped 
 2 to 5 cups, popped 
 More than 5 cups, popped 
 
112. How often did you eat pretzels? 
 
 NEVER (GO TO QUESTION 113) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
112a. Each time you ate pretzels, how many did 
you usually eat? 
 
 Fewer than 5 average twists 
 5 to 20 average twists 
 More than 20 average twists 
 
113. How often did you eat peanuts, walnuts, 
seeds, or other nuts?  
 
 NEVER (GO TO QUESTION 114) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
113a. Each time you ate peanuts, walnuts, seeds, 
or other nuts, how much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to ½ cup 
 More than ½ cup 
 
114. How often did you eat energy, high-protein, or 
breakfast bars (such as Power Bars, Balance, 
Clif, or others)? 
 
 NEVER (GO TO QUESTION 115) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
114a. Each time you ate energy, high-protein, or 
breakfast bars, how much did you usually eat? 
 
 Less than 1 bar  
 1 bar  
 More than 1 bar  
 
 
Question 112 appears in the next column 
Question 115 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
27 
Over the past month… 
 
115. How often did you eat yogurt (NOT including 
frozen yogurt)? 
 
 NEVER (GO TO QUESTION 116) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
115a. Each time you ate yogurt, how much did 
you usually eat? 
 
 Less than ½ cup or less than 1 container 
 ½ to 1 cup or 1 container 
 More than 1 cup or more than 1 container  
 
115b. How often was the yogurt you ate low-fat or 
fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
116. How often did you eat cottage cheese 
(including low-fat)? 
 
 NEVER (GO TO QUESTION 117) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
116a. Each time you ate cottage cheese, how 
much did you usually eat? 
 
 Less than ¼ cup 
 ¼ to 1 cup 
 More than 1 cup 
 
117. How often did you eat cheese (including low-fat; 
including on cheeseburgers or in sandwiches or 
subs)? 
 
 NEVER (GO TO QUESTION 118) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
 
117a. Each time you ate cheese, how much did 
you usually eat? 
 
 Less than ½ ounce or less than 1 slice 
 ½ to 1½ ounces or 1 slice 
 More than 1½ ounces or more than 1 slice 
 
117b. How often was the cheese you ate low-fat 
or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
118. How often did you eat frozen yogurt, sorbet, or 
ices (including low-fat or fat-free)? 
 
 NEVER (GO TO QUESTION 119) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
118a.  Each time you ate frozen yogurt, sorbet, or 
ices, how much did you usually eat? 
 
 Less than ½ cup or less than 1 scoop 
 ½ to 1 cup or 1 to 2 scoops 
 More than 1 cup or more than 2 scoops 
 
119. How often did you eat ice cream, ice cream 
bars, or sherbet (including low-fat or fat-free)? 
 
 NEVER (GO TO QUESTION 120) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
119a. Each time you ate ice cream, ice cream 
bars, or sherbet, how much did you usually 
eat? 
 
 Less than ½ cup or less than 1 scoop 
 ½ to 1½ cups or 1 to 2 scoops 
 More than 1½ cups or more than 2 scoops 
 
119b. How often was the ice cream you ate light, 
low-fat, or fat-free ice cream or sherbet? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
Question 118 appears in the next column 
Question 120 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
28 
Over the past month… 
 
120. How often did you eat cake (including low-fat or 
fat-free)? 
 
 NEVER (GO TO QUESTION 121) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
120a. Each time you ate cake, how much did you 
usually eat? 
 
 Less than 1 medium piece 
 1 medium piece 
 More than 1 medium piece 
 
121. How often did you eat cookies or brownies 
(including low-fat or fat-free)? 
 
 NEVER (GO TO QUESTION 122) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
121a. Each time you ate cookies or brownies, 
how much did you usually eat? 
 
 Less than 2 cookies or 1 small brownie 
 2 to 4 cookies or 1 medium brownie 
 More than 4 cookies or 1 large brownie 
 
 
122. How often did you eat doughnuts, sweet rolls, 
Danish, or pop-tarts?  
 
 NEVER (GO TO QUESTION 123) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
122a.  Each time you ate doughnuts, sweet rolls, 
Danish, or pop-tarts, how much did you 
usually eat? 
 
 Less than 1 piece 
 1 to 2 pieces 
 More than 2 pieces 
 
 
123. How often did you eat sweet muffins or 
dessert breads (including low-fat or fat-free)? 
 
 NEVER (GO TO QUESTION 124) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
123a. Each time you ate sweet muffins or dessert 
breads, how much did you usually eat? 
 
 Less than 1 medium piece 
 1 medium piece 
 More than 1 medium piece 
 
124. How often did you eat fruit crisp, cobbler, or 
strudel? 
 
 NEVER (GO TO QUESTION 125) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
124a. Each time you ate fruit crisp, cobbler, or 
strudel, how much did you usually eat? 
 
 Less than ½ cup 
 ½ to 1 cup 
 More than 1 cup 
 
125. How often did you eat pie?  
 
 NEVER (GO TO QUESTION 126) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
125a. Each time you ate pie, how much did you 
usually eat? 
 
 Less than ⅛ of a pie 
 About ⅛ of a pie 
 More than ⅛ of a pie 
 
 
Question 126 appears on the next page 
Question 123 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
29 
Over the past month… 
 
The next four questions ask about the kinds of 
pie you ate.  Please read all four questions 
before answering. 
 
125b. How often were the pies you ate fruit pie 
(such as apple, blueberry, others)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
125c.  How often were the pies you ate cream, 
pudding, custard, or meringue pie? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
125d.  How often were the pies you ate pumpkin 
or sweet potato pie? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
125e.  How often were the pies you ate pecan pie? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
126. How often did you eat chocolate candy?  
 
 NEVER (GO TO QUESTION 127) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
126a. Each time you ate chocolate candy, how 
much did you usually eat? 
 
 Less than 1 average bar or less than 1 ounce 
 1 average bar or 1 to 2 ounces 
 More than 1 average bar or more than 2 ounces 
 
 
127. How often did you eat other candy? 
 
 NEVER (GO TO QUESTION 128) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
127a.  Each time you ate other candy, how much 
did you usually eat? 
 
 Fewer than 2 pieces 
 2 to 9 pieces 
 More than 9 pieces 
 
128. How often did you eat eggs, egg whites, or egg 
substitutes (NOT counting eggs in baked 
goods and desserts)?  (Please include eggs in 
salads, quiche, and soufflés.) 
 
 NEVER (GO TO QUESTION 129) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
128a. Each time you ate eggs, how many did you 
usually eat? 
 
 1 egg 
 2 eggs 
 3 or more eggs 
 
128b. How often were the eggs you ate egg 
substitutes or egg whites only? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
128c.  How often were the eggs you ate regular 
whole eggs? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
128d.  How often were the eggs you ate cooked in 
oil, butter, or margarine? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
Question 129 appears on the next page 
Question 127 appears in the next column 


This is a sample form.  Do not use for scanning. 
 
30 
Over the past month… 
 
128e.  How often were the eggs you ate part of egg 
salad? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
 
 
 
129. How many cups of coffee, caffeinated or 
decaffeinated, did you drink (including coffee 
drinks such as Latte, Mocha, Frappuccino, etc.)? 
 
 NONE (GO TO QUESTION 130) 
 
 Less than 1 cup in  
 5–6 cups per week 
past month 
 1 cup per day 
 1–3 cups in past month 
 2–3 cups per day 
 1 cup per week 
 4–5 cups per day 
 2–4 cups per week 
 6 or more cups per day 
 
129a. How often was the coffee you drank 
decaffeinated? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
130. How many glasses, cans, or bottles of COLD or 
ICED tea, caffeinated or decaffeinated, did you 
drink? 
 
 NONE (GO TO QUESTION 131) 
 
 Less than 1 glass, can 
or bottle in past month 
 5–6 glasses, cans or 
bottles per week 
 1–3 glasses, cans or 
bottles in past month 
 1 glass, can or bottle per 
day 
 1 glass, can or bottle 
per week 
 2–3 glasses, cans or 
bottles per day 
 2–4 glasses, cans or 
bottles per week 
 4–5 glasses, cans or 
bottles per day 
 
 6 or more glasses, cans 
or bottles per day 
 
130a.  How often was the cold or iced tea you 
drank decaffeinated or herbal? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
  
130b. How often was the cold or iced tea you 
drank presweetened with either sugar or 
artificial sweeteners (such as Splenda, 
Equal, Sweet‟N Low or others)? 
 
 Almost never or never (GO TO QUESTION 131) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
130c. What kind of sweetener was added to your 
presweetened cold or iced tea most of the time? 
 
 
 Sugar or honey  
 
 Artificial sweeteners (such as Splenda, Equal, 
Sweet „N Low or others) 
 
131. How many cups of HOT tea, caffeinated or 
decaffeinated, did you drink? 
 
 NONE (GO TO QUESTION 132) 
 
 Less than 1 cup in  
 5–6 cups per week 
past month 
 1 cup per day 
 1–3 cups in past month 
 2–3 cups per day 
 1 cup per week 
 4–5 cups per day 
 2–4 cups per week 
 6 or more cups per day 
 
131a.  How often was the hot tea you drank 
decaffeinated or herbal? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
Question 131 appears in the next column 
Question 132 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
31 
Over the past month… 
 
132. Over the past month, did you add sugar, honey 
or other sweeteners to your tea or coffee (hot 
or iced)?  
 
 NO (GO TO QUESTION 133) 
 
 YES 
 
132a. How often did you add sugar or honey to 
your coffee or tea (hot or iced)? 
 
 Almost never or never (GO TO QUESTION 132c) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always  
 
 
132b.  Each time sugar or honey was added to your 
coffee or tea, how much was usually added? 
 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
132c. How often did you add artificial sweetener 
(such as Splenda, Equal, Sweet‟N Low or 
others) to your coffee or tea? 
 
 Almost never or never (GO TO QUESTION 133) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always  
 
132d. What kind of artificial sweetener did you 
usually use? 
 
 Equal or aspartame 
 Sweet‟N Low or saccharin 
 Splenda or sucralose 
 Herbal extracts or other kind 
 
132e. Each time artificial sweetener was added 
to your coffee or tea, how much was usually 
added? 
 
 Less than 1 packet or less than 1 teaspoon 
 1 packet or 1 teaspoon 
 More than 1 packet or more than 1 teaspoon 
 
 
133. Over the past month, did you add whiteners 
(such as cream, milk, or non-dairy creamer) to 
your tea or coffee?  
 
 NO (GO TO QUESTION 134) 
 
 YES 
 
133a. How often was non-dairy creamer added to 
your coffee or tea? 
 
 Almost never or never (GO TO QUESTION 133d) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always  
 
133b.  Each time non-dairy creamer was added to 
your coffee or tea, how much was usually 
used? 
 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
133c.  What kind of non-dairy creamer did you 
usually use? 
 
 Regular powdered 
 Low-fat or fat-free powdered 
 Regular liquid 
 Low-fat or fat-free liquid 
 
133d.  How often was cream or half and half 
added to your coffee or tea? 
 
 Almost never or never (GO TO QUESTION 133f) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always  
 
133e.  Each time cream or half and half was 
added to your coffee or tea, how much was 
usually added? 
 
 Less than 1 tablespoon 
 1 to 2 tablespoons 
 More than 2 tablespoons 
 
133f. How often was milk added to your coffee or 
tea? 
 
 Almost never or never (GO TO QUESTION 134) 
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always  
 
 
Question 133 appears in the next column 
Question 134 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
32 
Over the past month… 
 
133g.  Each time milk was added to your coffee or 
tea, how much was usually added? 
 
 Less than 1 tablespoon 
 1 to 3 tablespoons 
 More than 3 tablespoons 
 
133h.  What kind of milk was usually added to your 
coffee or tea? 
 
 Whole milk 
 2% milk 
 1% milk 
 Skim, nonfat, or ½% milk 
 Evaporated or condensed (canned) milk 
 Soy milk 
 Rice milk 
 Other 
 
134. How often was sugar or honey added to foods 
you ate?  (Please do not include sugar in coffee, 
tea, other beverages, or baked goods.) 
 
 NEVER (GO TO INTRODUCTION TO  
QUESTION 135) 
 
 1 time in past month 
 3–4 times per week 
 2–3 times in past month 
 5–6 times per week 
 1 time per week 
 1 time per day  
 2 times per week 
  2 or more times per day 
 
134a.  Each time sugar or honey was added to 
foods you ate, how much was usually 
added? 
 
 Less than 1 teaspoon 
 1 to 3 teaspoons 
 More than 3 teaspoons 
 
The following questions are about the kinds of 
margarine, mayonnaise, sour cream, cream 
cheese, and salad dressing that you ate.  If 
possible, please check the labels of these foods 
to help you answer. 
 
135. Over the past month, did you eat margarine? 
 
 NO (GO TO QUESTION 136) 
 
 YES 
 
135a. How often was the margarine you ate light, 
low-fat, or fat-free (stick or tub)? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
136. Over the past month, did you eat butter? 
 
 NO (GO TO QUESTION 137) 
 
 YES 
 
136a.  How often was the butter you ate light or 
low-fat? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
  
137. Over the past month, did you eat mayonnaise 
or mayonnaise-type dressing? 
 
 NO (GO TO QUESTION 138) 
 
 YES 
 
137a. How often was the mayonnaise you ate 
light, low-fat or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
138. Over the past month, did you eat sour cream? 
 
 NO (GO TO QUESTION 139) 
 
 YES 
 
138a.  How often was the sour cream you ate light, 
low-fat, or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
 
 
 
 
 
 
Question 136 appears in the next column 
Question 139 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
33 
Over the past month… 
 
139. Over the past month, did you eat cream 
cheese? 
 
 NO (GO TO QUESTION 140) 
 
 YES 
 
139a.  How often was the cream cheese you ate 
light, low-fat, or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
140. Over the past month, did you eat salad 
dressing? 
 
 NO (GO TO INTRODUCTION TO QUESTION 141) 
 
 YES 
 
140a.  How often was the salad dressing you ate 
light, low-fat or fat-free? 
 
 Almost never or never  
 About ¼ of the time 
 About ½ of the time 
 About ¾ of the time 
 Almost always or always 
 
The following two questions ask you to 
summarize your usual intake of vegetables and 
fruits.  Please do not include salads, potatoes, or 
juices. 
 
141. Over the past month, how many servings of 
vegetables (not including salad or potatoes) did 
you eat per week or per day? 
 
 Less than 1 per week 
 2 per day 
 1–2 per week 
 3 per day 
 3–4 per week 
 4 per day 
 5–6 per week 
 5 or more per day 
 1 per day 
 
 
142. Over the past month, how many servings of fruit 
(not including juices) did you eat per week or per 
day? 
 
 Less than 1 per week 
 2 per day 
 1–2 per week 
 3 per day 
 3–4 per week 
 4 per day 
 5–6 per week 
 5 or more per day 
 1 per day 
 
 
143. Over the past month, which of the following 
foods did you eat AT LEAST THREE TIMES?  
(Mark all that apply.) 
 
 Avocado, guacamole 
 Olives 
 Cheesecake 
 Oysters 
 Chocolate, fudge, or 
 Pickles or pickled 
butterscotch toppings 
vegetables or fruit 
or syrups 
 Plantains 
 Chow mein noodles 
 Pork neck bones, hock, 
 Croissants 
head, feet 
 Dried apricots 
 Pudding or custard 
 Egg rolls 
 Veal, venison, lamb 
 Granola bars 
 Whipped cream, regular 
 Hot peppers 
 Whipped cream,  
 Jell-O, gelatin 
 Mangoes 
substitute 
 Milkshakes or 
 
 
ice-cream sodas 
 NONE 
 
144. For ALL of the past month, have you followed 
any type of vegetarian diet? 
 
 NO (GO TO INTRODUCTION TO QUESTION 145) 
 
 YES 
 
144a.  Which of the following foods did you 
TOTALLY EXCLUDE from your diet?  
(Mark all that apply.) 
 
 Meat (beef, pork, lamb, etc.) 
 Poultry (chicken, turkey, duck) 
 Fish and seafood 
 Eggs 
 Dairy products (milk, cheese, etc.) 
 
 
 
 
 
   
 
Introduction to Question 145 appears on the next page 


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34 
The next questions are about your use of vitamin 
pills or other supplements. 
 
145. Over the past month, did you take any 
multivitamins, such as One-a-Day-, Theragran-, 
Centrum-, or Prenatal-type multivitamins (as pills, 
liquids, or packets)? 
 
 NO (GO TO INTRODUCTION TO QUESTION 147) 
 
 YES 
 
146. How often did you take One-a-day-, Theragran-, 
Centrum- or Prenatal-type multivitamins? 
 
 1–3 days in past month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
146a. Did your multivitamin usually contain 
minerals (such as iron, zinc, etc.)? 
 
 NO 
 YES 
 Don't know 
 
146b. Over the past month, did you take any 
vitamins, minerals, or other herbal 
supplements other than your multivitamin? 
 
 NO 
 
 
Thank you very much for completing this 
questionnaire!  Because we want to be 
able to use all the information you have 
provided, we would greatly appreciate it 
if you would please take a moment to 
review each page making sure that you:  
 Did not skip any pages and 
 Crossed out the incorrect answer and 
circled the correct answer if you made 
any changes. 
 
 YES (GO TO INTRODUCTION TO 
QUESTION 147 
 
 
These last questions are about the vitamins, 
minerals, or herbal supplements you took that are 
NOT part of a One-a-day-, Theragran-, or 
Centrum-type of multivitamin. 
 
Over the past month… 
 
147. How often did you take Antacids such as 
Tums or Rolaids? 
 
 NEVER (GO TO QUESTION 148) 
 
 1–3 days per month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
147a. When you took Antacids such as Tums or 
Rolaids, about how many tablets or 
lozenges did you take in one day? 
 
 Less than 1 
 1 
 2 
 3  
 4 or more 
 Don't know 
 
147b. Was your antacid usually “extra strength”? 
 
 NO 
 YES 
 Don't know 
 
148. How often did you take Calcium (with or without 
Vitamin D) (NOT as part of a multivitamin in 
Question 146 or antacid in Question 147)?  
 
 NEVER (GO TO QUESTION 149) 
 
 1–3 days per month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
148a. When you took Calcium , about how much 
elemental calcium did you take in one day? 
 
 (If possible, please check the label for 
elemental calcium.) 
 
 Less than 500 mg 
 500–599 mg 
 600–999 mg 
 1,000 mg or more 
 Don't know 
 
148b. Did your Calcium usually contain Vitamin D? 
 
 NO 
 YES 
 Don't know 
Introduction to Question 147 appears in the next column 
Question 149 appears on the next page 


This is a sample form.  Do not use for scanning. 
 
35 
Thank you very much for completing this 
questionnaire!  Because we want to be able 
to use all the information you have provided, 
we would greatly appreciate it if you would 
please take a moment to review each page 
making sure that you: 
 
Did not skip any pages and 
 
Crossed out the incorrect answer and 
circled the correct answer if you made 
any changes. 
Over the past month… 
 
148c. Did your Calcium usually contain 
Magnesium? 
 
 NO 
 YES 
 Don't know 
 
148d. Did your Calcium usually contain Zinc? 
 
 NO 
 YES 
 Don't know 
 
149. How often did you take Iron (NOT as part of a 
multivitamin in Question 146)? 
 
 NEVER 
 
 1–3 days per month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
150. How often did you take Vitamin C (NOT as part 
of a multivitamin in Question 146)? 
 
 NEVER (GO TO QUESTION 151) 
 
 1–3 days per month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
150a. When you took Vitamin C, about how much 
did you take in one day? 
 
 Less than 500 mg 
 500–999 mg 
 1,000–1,499 mg 
 1,500–1,999 mg 
 2,000 mg or more 
 Don't know 
 
151. How often did you take Vitamin E (NOT as part 
of a multivitamin in Question 146)?  
 
 NEVER (GO TO INTRODUCTION TO 
QUESTION 152) 
 
 1–3 days per month 
 1–3 days per week 
 4–6 days per week 
 Every day 
 
151a.  When you took Vitamin E, about how much 
did you take in one day? 
 
 Less than 400 IU 
 400–799 IU 
 800–999 IU 
 1,000 IU or more 
 Don't know 
 
The last two questions ask you about other 
supplements you took more than once per week. 
 
152. Please mark any of the following single 
supplements you took more than once per 
week (NOT as part of a multivitamin in 
Question 147): 
 
 B-6 
 B-complex  
 B-12 
 Beta-carotene 
 Folic acid/folate 
 Magnesium 
 
 
 Occu-vite/Eye health 
 
 Potassium 
 
 Selenium 
 
 Vitamin A 
 
 Vitamin D 
 
 Zinc 
 
153. Please mark any of the following herbal, 
botanical, or other supplements you took 
more than once per week. 
 
 Chondroitin 
 Coenzyme Q-10 
 Echinacea 
 Energy supplements 
 Fish oil/omega 3‟s 
 Flaxseed/oil 
 Garlic 
 Ginger 
 Ginkgo biloba  
 
 
 Ginseng  
 
 Glucosamine/ 
chondroitin 
 
 Peppermint  
 
 Probiotics 
 
 Saw palmetto 
 
 Soy supplement 
 
 Sports supplements 
 
 St. John's wort 
 
 Other 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Introduction to Question 152 appears in the next column