Clinical Trial Considerations for Functional Food, Food Ingredient, and Dietary

Supplement Manufacturers

GETTING IT RIGHT THE FIRST TIME:

WHITE PAPER

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Clinical trials are a key component required for substantiating claims of functional foods,

food ingredients, and dietary supplements. Many factors must be considered before,

during, and after a trial in order to offer the best chances for success. This paper

provides an overview of the major considerations involved in the development, design,

implementation, and reporting of blinded, randomized clinical trials for non-drug claims.

Is a Clinical Trial Right for my Company?

Before considering the subtleties of clinical study design and construction, the decision

of whether or not to even conduct a clinical trial must be addressed. When considering

a clinical trial, companies should, above all, consider the regulatory environment in

which they want to launch their product. Depending on the jurisdiction, claims may

need to be substantiated by clinical trial data and/or approved by regulatory agencies;

some regulatory agencies also require submission of study protocols and other

supporting documents for their review before a clinical trial can begin. In the United

States, for example, the FDA and FTC regulate product claims. The FDA offers guidance

on Qualified Health Claims (link) and Structure/Function Claims (link), while the FTC

regulates health claims and considers two double-blind, placebo-controlled studies

conducted at two independent sites the gold standard to support a health claim. In

addition to meeting regulatory standards, it is important for companies to differentiate

themselves from the competition in saturated markets. Considering that many

companies continue to make unsubstantiated claims with no or weak supportive data

(e.g. testimonials), product claims backed up by clinical trial results offer a way for

companies to differentiate themselves from the pack. Company sales and marketing

departments can also make effective use of clinical trial findings when communicating

the benefits of a product to the medical and scientific communities or directly to

consumers. Finally, the cost of a high-quality clinical trial must be considered: the price

of adequately sized trials for non-drug products is typically six figures, requiring a

financial commitment on the part of the sponsoring company along with adequate

resources to sustain the trial during implementation, analysis, and reporting.

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Clinical Trial Planning

The planning and design of a clinical trial to demonstrate attainment of a specific

clinical endpoint is arguably the most important phase of the clinical trial lifecycle. At

Sprim, we take a slightly different approach to clinical trial planning. Instead of

addressing the question, ―What is the ideal clinical study design to test the effectiveness

and safety of my product for the clinical endpoint "X"?‖, we ask, ―What claims would you

ultimately like to make for your product?‖ Identifying desired product claims and then

working backwards to identify appropriate endpoints and a trial design that support

these claims is much more efficient than the approach frequently used by functional

food and supplement manufacturers: to ―measure everything and see what's significant‖

(an exercise unlikely to impress regulators due to the high probability of an alpha error,

discussed below). A focused study design with well-defined, relevant endpoints using

an appropriate subject population and sample size, and with a sufficient follow-up

period, not only improves the odds of study success but also allows accurate budgeting

and creation of a reasonable timeline.

Study Design

Given the increasing scrutiny of clinical trials by regulatory agencies such as FDA, FTC,

and EFSA, an appropriate study design is critical. The double-blind, randomized,

placebo-controlled trial represents the gold standard by which product safety and

effectiveness are assessed. Although a double-blind, randomized, placebo-controlled

trial is not necessary for all research questions (e.g., feasibility studies), this design is

least subject to bias and therefore the most acceptable in support of a claim. Double

blinding ensures that the subjects and the investigators are unaware of each subject’s

treatment group. Randomization refers to the process of allocating subjects to a

treatment group in pre-specified random order, instead of allowing the subject or

investigator to make this selection. Control groups (which may receive placebo or a

different product) are important, since product effectiveness can only be demonstrated

if statistically significant improvements are demonstrated in relation to changes in the

control group, not just in relation to baseline values. A common error is to claim

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effectiveness of a product if a clinical improvement was noted from pre-treatment to

post-treatment. However, if the placebo group enjoyed the same pre- to post-

improvement, then the product was actually not effective at all. "Placebo effect" refers

to the tendency of subjects to improve on placebo treatment; this effect has been noted

to have a particularly powerful influence on certain endpoints frequently investigated in

non-drug studies.

Blinded, randomized clinical trials most commonly use 2 or more parallel groups; in this

design, subjects are randomly assigned to a group at entry, an intervention is

administered over a pre-specified time period (typically weeks or months), data are

collected without knowing which subjects received which intervention, and unblinding

and analysis occurs only after all the data have been collected and the database has

been locked (i.e., no changes in the data can be made).

Common Errors in the Design Stage

Design of a clinical trial presents ample opportunity for errors that may not be

recognized until the trial is underway or completed. Commonly seen errors include

those below:

Multiple endpoints: Many studies include multiple efficacy endpoints. While exploring

several outcomes is acceptable, a single primary efficacy endpoint should be identified

in the protocol, and the other endpoints designated as secondary or ancillary. Results

from the primary endpoint determine whether, in the end, the study is successful or

negative. Failure of the primary endpoint and success on one or more secondary

endpoints is often insufficient to support claims.

Use of non-validated instruments to measure endpoints: All efficacy endpoints

should be assessed using instruments (typically questionnaires) that have been

validated in an appropriate population (i.e., a population with language and culture

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relevant to the subjects in the clinical trial and the population to which its results will be

generalized). "Making up" a set of questions to assess an endpoint is not sufficient.

There are validated instruments designed to assess a surprisingly wide range of effects,

including gastrointestinal symptoms, sexual function, quality of life, sleep quality, and

altitude sickness, to name only a few. Clinical endpoints, such as prevention of

respiratory tract infection, are also appropriate when the criteria for the endpoint are

clearly and quantitatively defined in the protocol.

Overly strict entrance criteria: While clinical trials target a certain type of subject who

is most likely to respond to a sponsor's product, too-restrictive eligibility criteria will

slow enrollment or even make enrollment impossible. Generally, exclusions should be

limited to factors that make a subject non-evaluable for one or more study endpoints,

are likely to cause early withdrawal from study, or that pose a safety risk to the subject.

Failing to enroll subjects of both genders (where appropriate to the product) and

various races and ethnicities narrows a product claim, as does exclusion of some age

groups.

Failure to address safety: All studies should address product safety by reporting all

adverse events that occur on study. In trials in which clinical laboratory data are

collected, the results of these over the study period should be assessed in the analysis

stage for clinically significant changes within each product group or dose level.

Too many groups: Many sponsors, unsure of the optimal dose of their product,

undertake large and expensive studies that attempt to both identify the best dose and

to also support the product efficacy claim. A better plan is to carry out, initially, a small

dose-ranging study to identify a promising dose level, and then do a larger study with

the selected dose group vs. placebo.

Insufficient Power: Failure to consider power is perhaps one of the biggest weaknesses

of clinical trials. A common request is to conduct a trial with ―about 20 subjects per

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group‖. While this might be a reasonable sample size in some instances, it is important

to conduct a formal power analysis to estimate sample size as opposed to guessing.

"Power" is defined as the ability of the study to detect a difference between study arms

when a true difference exists in the populations from which they were drawn. Studies

may be underpowered due to lack of understanding of the importance of power when

setting the study size, or because the difference between the study groups on the

primary endpoint is smaller than anticipated, or because the variability of the endpoint

is greater.

Power is one of the 4 major determinants of sample size, the others being alpha level

(most often set at 0.05 – this is the probability of observing a chance treatment effect in

the study sample that does not exist in the population), difference between the groups

on the primary endpoint, and measurement variability of the primary endpoint. Before

the protocol is written, the scientific literature should be examined to determine

reasonable differences that can be expected between the study groups, as well as the

variability of the endpoint. When calculating sample size, power is generally set at 80%

or above, giving an 80%-or-better chance of detecting a true effect and having a

successful study.

Many investigators make the mistake of underestimating variability and/or

overestimating inter-group differences in hopes of having a small, inexpensive study.

Also, for many endpoints information on inter-group differences and variability is not

easily found in the literature. In such a case, the concept of "effect size‖ is very useful in

calculating an adequate sample size and avoiding an underpowered study. "Effect size"

for a continuous endpoint (for example, a score on a questionnaire), is the inter-group

difference divided by the common standard deviation of the endpoint in the 2 groups.

For example, if an endpoint measurement is believed to have a mean of 50 in the active

group and 70 in the placebo group, and in each group the standard deviation of the

mean is 20, then the effect size can be calculated as

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(mean 1 – mean 2 )/SD = (70 – 50)/20 = 1.0 = effect size

Cohen considers a "small" effect size to be 0.2, a "medium" effect size to be 0.5, and a

"large" effect size to be 0.8. When calculating sample sizes, effect size can be used as a

proxy in the absence of knowledge about inter-group differences and standard

deviation. While the effect size discussed here applies only to endpoints measured on a

continuous scale, similar estimates of effect size are available when an endpoint is

expressed as a proportion or correlation. In clinical trials of supplements and functional

foods, assuming a small effect size is more realistic than assuming a large one. Thus,

effect sizes in the 0.2 – 0.4 range are suitable to use when exploring sample size

requirements for these studies.

We, at Sprim, have an obligation to not only inform the client of a statistically

appropriate sample size based on the considerations discussed above but also to

propose potential solutions, such as selecting a different endpoint that requires fewer

subjects, or conducting the trial in a more cost-effective geographical location.

Undertaking, first, a small pilot study, that can be expanded if indicated by a successful

interim analysis, is also an option.

Alpha error: When designing the study, an alpha level (most commonly 0.05) should be

selected at which to test the primary endpoint. Only success on this endpoint can

determine the success of failure of the trial. While secondary endpoints can also be

tested, success on one or more of these does not carry the weight of a success on the

primary endpoint because of the problem of alpha error, which is the increasing

probability of obtaining a statistically significant result as the number of tests conducted

increases. For example, in a study with 20 different endpoints in which each is tested at

alpha = 0.05, one endpoint is expected to have a p-value less than 0.05 by chance alone.

In the rare case where 2 or more endpoints are equally important, each must be tested

at a partitioned alpha level to give an overall alpha of 0.05.

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Inappropriate analysis: While in the protocol-writing stage considerable thought

should be given to the statistical methods that will be used for data analysis.

Appropriate methods are determined by the level of measurement of an outcome

variable (continuous, ranked, or categorical), the number of groups being compared,

any baseline differences between the study groups, and other factors.

Study Feasibility

Even the best-laid plans (i.e. the study design) are useless unless the feasibility of

conducting the trial has been considered. Common examples of a mismatch in design

versus implementation are described below:

Design: A probiotic trial designed to enroll 600 subjects with irritable bowel syndrome

according to the Rome III criteria

Implementation problem: Adequate statistical power, but enrolling this many subjects

who meet strict study entry criteria would take a very long time or a very large budget

Design: A soluble fiber trial that mandates a dietary recall every day for 8 weeks

Implementation problem: Comprehensive assessment of caloric and macronutrient

intake, but unnecessarily burdensome for the subject, ultimately leading to subject

dropout or to missing dietary intake data due to noncompliance

Design: A ―cognitive enhancer‖ trial that requires supplementation of 2 capsules three

times a day for 26 weeks

Implementation problem: Adequate product dosing and duration of supplementation,

but high chance of subject dropout due to burdensome supplementation regimen

Study Cost Considerations

An important consideration in the clinical trial development process for all companies is

cost. Cost is highly dependent on sample size, type of outcome assessments, number of

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follow-up visits, and geographic location of study, among others. Sprim understands

that, unlike pharmaceutical companies, most food, ingredient, and dietary supplement

companies do not have millions of dollars to spend on clinical trials. Sprim lowers

clinical trial costs by offering a global presence (clinical trial costs are lower in some

countries than others), study design alternatives (e.g. interim analyses), and using

preferred service providers.

Clinical Trial Execution

Proper execution of a clinical trial depends on selecting the right partners. Choice of

the best clinical trial partner depends on several factors such as timeline, budget,

services, and experience. Below are some examples of clinical trial partners:

University: The advantages of using a university to conduct a clinical trial are the

expertise offered by the principal investigator and his or her research staff and a large

pool of healthy subjects from which to recruit. Drawbacks of universities include longer

IRB approval times compared to central IRBs, higher prices due to overhead costs, and

the risks associated with using a single site, such as a homogenous subject population

and lack of a backup plan in the case of slow enrollment.

Clinical Research Site (free-standing clinic or physician's office): Clinical research sites

often possess large databases of subjects with various pathologies and, therefore,

enrollment of diseased subjects is often quicker than with universities. A disadvantage

of using these sites is that trials in the dietary supplement area typically focus on overall

healthy subjects and, therefore, these databases are of little use. Furthermore, clinical

research sites recruit homogenous subject populations from a narrow geographical area,

which can limit the generalizability of the study findings. Lastly, the use of a single site

is risky since poor enrollment rates or other unforeseen problems can delay study

completion for months or even years.

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CRO: Contract Research Organizations (CROs) vary in size from large international firms

to small niche operations. CROs are usually more responsive in terms of enrollment and

have the flexibility to work with multiple sites at the same time, which facilitates

enrollment and improves the generalizability of the study findings by enrolling from

multiple geographical regions. Disadvantages of CROs may include the inability to

conduct trials internationally, high costs due to pharma-like business models, and lack

of subject matter expertise specific to health and the functional food, food ingredient,

and dietary supplement industries.

Clinical Trial Reporting

The final phase of a clinical trial is reporting the results of the trial. This starts with

performing the biostatistical analyses that were pre-specified in the study protocol

and/or the statistical analysis plan and developing a formal and thorough Clinical Study

Report (CSR). The ICH E3 guidance document for structure and content of CSRs (link) is

a template that should be utilized in order to provide a comprehensive report of the

study design, conduct, and outcomes.

Beyond the development of a CSR, publication of study results in a peer-reviewed

journal is one of the best ways to gain exposure of your product to medical

professionals and consumers alike. Sprim takes a unique and comprehensive approach

to publication planning. Sprim adheres to a common set of publication planning and

execution guidelines in order to establish consistency across Sprim offices worldwide

and to ensure that all steps are taken to reach the highest chances of publication.

Two items critical to publication success are actually addressed before a clinical trial

even begins—namely, a strong study design and clinical trial registration. Successful

publication is highly dependent on development of a strong study design before the

trial begins. Sprim has particular expertise in the development of strong research

designs, while also considering client budgets and timelines to achieve a win-win

situation for all—a trial completed on time, within budget, and published in a reputable

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journal. In addition, Sprim strongly encourages all of our clients to register clinical trials

on Clinicaltrials.gov (link) or a similar registry, per the guidelines of the International

Committee of Medical Journal Editors. Many journals require trials to be registered

before the first subject in a trial is enrolled, in order to be considered for publication. By

not registering a trial or by registering after enrollment has begun, the number of

potential journals that are available to publish your manuscript is significantly reduced.

Numerous publication planning activities occur after a clinical trial is complete.

Selection of a peer-reviewed journal is made by considering many different factors

including: a) clinical trial registration requirements, b) impact factor (which reflects the

number of citations of articles published in the journal), c) length of peer review/time to

publication, d) Sponsor urgency for publication, e) manuscript rejection rate, f)

publication costs, g) target audience and size of audience, h) indexing in Medline, and i)

marketing needs. Sprim identifies journals that are reputable where the research has a

strong chance of acceptance. Not every study, however, can be published in the best

journals—and we know this. This knowledge helps manuscripts that we develop gain

quick acceptance in strong, appropriate journals instead of languishing for months or

even years after multiple rejections from poorly selected journals.

Sprim has an established track record of publications across a broad range of

therapeutic areas. We offer expertise in all aspects of clinical research ranging from

study design, protocol development, study conduct, study reporting and publication, to

name a few. Overall, Sprim is well positioned to help our clients achieve publication

success. Below is a sample of our recent published works.

Gastroenterology Gao XW, Mubasher M, Fang CY, Reifer C, and Miller LE. Dose-response efficacy of a proprietary probiotic formula of lactobacillus acidophilus CL1285 and lactobacillus casei LBC80R for antibiotic-associated diarrhea and clostridium difficile-associated diarrhea prophylaxis in adult patients. American Journal of Gastroenterology 105:1636-1641, 2010. Waller PA, Gopal PK, Leyer GJ, Ouwehand AC, Reifer C, Stewart ME, and Miller LE. Dose-response effect of Bifidobacterium lactis HN019 on whole gut transit time and functional gastrointestinal symptoms in adults. Scandinavian Journal of Gastroenterology. Jun 13, 2011 [Epub ahead of print].

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Ophthalmology Bucheli P, Vidal K, Shen L, Gu Z, Zhang C, Miller LE, and Wang J. Goji berry effects on macular characteristics and plasma antioxidant levels. Optometry and Vision Science 88:257-262, 2011.

Metabolism Li S, Deremaux L, Pochat M, Wils D, Reifer C, and Miller LE. NUTRIOSE® FB dietary fiber supplementation improves insulin resistance and determinants of metabolic syndrome in overweight men: a double-blind, randomized, placebo-controlled study. Applied Physiology, Nutrition and Metabolism 35:773-782, 2010. Guerin-Deremaux L, Li S, Pochat M, Wils D, Mubasher M, Reifer C, and Miller LE. Effects of NUTRIOSE(®) dietary fiber supplementation on body weight, body composition, energy intake, and hunger in overweight men. International Journal of Food Science and Nutrition 62:628-635, 2011.

Gynecology Ya W, Reifer C, and Miller LE. Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double-blind, randomized, placebo-controlled study. American Journal of Obstetrics and Gynecology 203:120.e1-6, 2010.

Immunology Leyer GJ, Li S, Mubasher ME, Reifer C, and Ouwehand AC. Probiotic effects on cold and influenza-like symptom incidence and duration in children. Pediatrics 124:e172-179, 2009. Clerici M, Pauze E, de Jong A, Biasin M, and Miller LE. Evaluation of bovine-derived lacteal complex supplementation on gene expression in BALB/c mice. Nutrition and Dietary Supplements. In press.

Trial Conduct & Design Miller LE and Stewart ME. The blind leading the blind: use and misuse of blinding in randomized controlled trials. Contemporary Clinical Trials 32:240-243, 2011.

The Sprim Advantage

Through our Research and Clinical Services (RCS) we have gained extensive expertise in

running clinical trials for the functional foods, food ingredients, dietary supplements,

and consumer products. We have an international presence with offices in 9 countries

including the United States, Mexico, Brazil, China, Thailand, Australia, and in Europe.

Our services are customizable and include study design, protocol development, IRB

submissions, study management, biostatistics, data management, publication planning

and development.

More than a CRO, Sprim is a global consulting firm focused on innovation in human

health, dedicated to leveraging its global expertise and networks to deliver effective

solutions for its clients. Through hundreds of projects globally, Sprim has proven its

ability to seamlessly and cost effectively integrate its scientific, commercial, and

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regulatory expertise to deliver well designed and well executed solutions for propelling

client innovations to market. Sprim clients include market leaders and technology

innovators in the life sciences including: consumer health products, food & ingredients,

supplements, cosmetics, medical devices and pharmaceuticals.

If you would like to know more about Sprim, please contact:

Gabriel Paulino, PhD

Manager of Business Development

gabriel.paulino@sprim.com

Tel: +1 (415) 291-2019