METHODS: A cross-sectional survey was conducted among a sample of 416 (53% male and 47% female) undergraduate students, aged 18-26 years old, between January 6 and April 6, 2019, from colleges of Health Sciences at Jazan University in the Kingdom of Saudi Arabia (K.S.A). Students completed a self-administered questionnaire and recorded their measured anthropometric parameters.

RESULTS: The prevalence of overweight (20.4%) and obesity (14.9%) were relatively high among the participants. There were statistically significant associations between Body Mass Index (BMI) and the different settings of food consumption (i.e., dining on a table (or) in the Islamic way: squatting on the ground) (p<0.001)). BMI was also associated with students' dietary habits regarding consuming food, snacks, and drinking carbonated beverages while watching television (p<0.001), as well as consuming the same pattern of food/drink while watching television, playing video games on mobile phones or computers (p<0.001). Nearly most of the students were oblivious to the fact that metabolic syndrome, reproductive disorders, respiratory disorders along with liver and gallbladder diseases are some of the health risks associated with obesity.

APPROACH & RESULTS: NAFLD knowledge surveys containing 54 and 59 questions covering three domains (Epidemiology/Pathogenesis, Diagnostics, and Treatment) were completed electronically by hepatologists, gastroenterologists (GEs), endocrinologists (ENDOs) and primary care physicians (PCPs) from 40 countries comprising 5 Global Burden of Disease (GBD) super-regions. Over 24 months, 2202 surveys were completed (488 hepatologists, 758 GEs, 148 ENDOs, and 808 PCPs; 50% High-Income GBD super-region, 27% from North Africa and Middle East, 12% Southeast Asia, and 5% South Asian and Latin America). Hepatologists saw the greatest number of NAFLD patients annually: median (IQR) 150 (60-300) vs. 100 (35-200) for GEs, 100 (30-200) for ENDOs, and 10 (4-50) for PCPs (all p<0.0001). The primary sources of NAFLD knowledge acquisition for hepatologists were international conferences (33% vs. 8-26%) and practice guidelines for others (39-44%). Internet was the second most common source of NAFLD knowledge for PCPs (28%). NAFLD knowledge scores were higher for hepatologists than GEs: Epidemiology 62% vs. 53%, Diagnostics 80% vs. 73%, Treatment 61% vs. 58% (p<0.0001) and ENDOs scores were higher than PCPs: Epidemiology 70% vs. 60%, Diagnostics 71% vs. 64%, Treatment 79% vs. 68% (p<0.0001). Being a hepatologist or ENDO was associated with higher knowledge scores than GE or PCP, respectively (p<0.05). Higher NAFLD knowledge scores were independently associated with greater number of NAFLD patients seen (p<0.05).

METHODS: Clinical, laboratory, and PRO data (Chronic Liver Disease Questionnaire-nonalcoholic steatohepatitis [NASH], Functional Assessment of Chronic Illness Therapy-Fatigue, and the Work Productivity and Activity Index) were collected from NAFLD patients seen in real-world practices and enrolled in the Global NAFLD/NASH Registry encompassing 18 countries in 6 global burden of disease super-regions.

RESULTS: Across the global burden of disease super-regions, NAFLD patients (n = 5691) were oldest in Latin America and Eastern Europe and youngest in South Asia. Most men were enrolled at the Southeast and South Asia sites. Latin America and South Asia had the highest employment rates (>60%). Rates of cirrhosis varied (12%-21%), and were highest in North Africa/Middle East and Eastern Europe. Rates of metabolic syndrome components varied: 20% to 25% in South Asia and 60% to 80% in Eastern Europe. Chronic Liver Disease Questionnaire-NASH and Functional Assessment of Chronic Illness Therapy-Fatigue PRO scores were lower in NAFLD patients than general population norms (all P < .001). Across the super-regions, the lowest PRO scores were seen in Eastern Europe and North Africa/Middle East. In multivariate analysis adjusted for enrollment region, independent predictors of lower PRO scores included younger age, women, and nonhepatic comorbidities including fatigue (P < .01). Patients whose fatigue scores improved over time experienced a substantial PRO improvement. Nearly 8% of Global NAFLD/NASH Registry patients had a lean body mass index, with fewer metabolic syndrome components, fewer comorbidities, less cirrhosis, and significantly better PRO scores (P < .01).

METHODS: In this multicenter randomized trial, critically ill patients will be randomized to receive supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition to achieve a high amount of enteral protein (range of 2-2.4 g/kg/day) or no supplemental enteral protein to achieve a moderate amount of enteral protein (0.8-1.2 g/kg/day). The primary outcome is 90-day all-cause mortality; other outcomes include functional and health-related quality-of-life assessments at 90 days. The study sample size of 2502 patients will have 80% power to detect a 5% absolute risk reduction in 90-day mortality from 30 to 25%. Consistent with international guidelines, this statistical analysis plan specifies the methods for evaluating primary and secondary outcomes and subgroups. Applying this statistical analysis plan to the REPLENISH trial will facilitate unbiased analyses of clinical data.

CONCLUSION: Ethics approval was obtained from the institutional review board, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia (RC19/414/R). Approvals were also obtained from the institutional review boards of each participating institution. Our findings will be disseminated in an international peer-reviewed journal and presented at relevant conferences and meetings.