The global fatty liver disease Sustainable Development Goal country score for 195 countries and territories

Abstract

Background and Aims:

Fatty liver disease is highly prevalent, resulting in overarching wellbeing and economic costs. Addressing it requires comprehensive and coordinated multisectoral action. We developed a fatty liver disease Sustainable Development Goal (SDG) country score to provide insights into country-level preparedness to address fatty liver disease through a whole-of-society lens.

Approach and Results:

We developed 2 fatty liver disease–SDG score sets. The first included 6 indicators (child wasting, child overweight, noncommunicable disease mortality, a universal health coverage service coverage index, health worker density, and education attainment), covering 195 countries and territories between 1990 and 2017. The second included the aforementioned indicators plus an urban green space indicator, covering 60 countries and territories for which 2017 data were available. To develop the fatty liver disease–SDG score, indicators were categorized as “positive” or “negative” and scaled from 0 to 100. Higher scores indicate better preparedness levels. Fatty liver disease–SDG scores varied between countries and territories (n = 195), from 14.6 (95% uncertainty interval: 8.9 to 19.4) in Niger to 93.5 (91.6 to 95.3) in Japan; 18 countries and territories scored > 85. Regionally, the high-income super-region had the highest score at 88.8 (87.3 to 90.1) in 2017, whereas south Asia had the lowest score at 44.1 (42.4 to 45.8). Between 1990 and 2017, the fatty liver disease–SDG score increased in all super-regions, with the greatest increase in south Asia, but decreased in 8 countries and territories.

Conclusions:

The fatty liver disease–SDG score provides a strategic advocacy tool at the national and global levels for the liver health field and noncommunicable disease advocates, highlighting the multisectoral collaborations needed to address fatty liver disease, and noncommunicable diseases overall.

INTRODUCTION

Fatty liver disease refers to a range of conditions in which excess fat builds up in the liver and is largely unknown among the general population,¹ health policy makers, and the global public health community.² This potentially serious condition is estimated to affect about one in 3 adults globally³ and is increasingly problematic in children and adolescents.^4–6 Disease severity is measured through the degree of fibrosis; however, population-based estimates of advanced fibrosis associated with fatty liver disease are limited. Data from Germany have shown it to be around 1%,⁷ whereas a Korean study estimated it at 2.6%.⁸ A review of studies in patients at risk of clinically significant liver disease in a general population setting found that the prevalence of advanced liver fibrosis ranged between 0.9% and 2.0%, and cirrhosis between 0.1% and 1.7%.⁹ Fatty liver disease, and particularly the more aggressive condition NASH, have a substantial impact on individual health,¹⁰ burdening health systems, causing substantial economic encumbrance, and increasing wellbeing costs.¹¹

Beyond being a leading cause of cirrhosis¹² and liver cancer,^13,14 fatty liver disease shares a close bidirectional relationship with other highly prevalent noncommunicable diseases (NCDs), most notably cardiovascular disease, type 2 diabetes mellitus, obesity, and nonhepatic cancers.^15–17 In the majority of patients, fatty liver disease emerges in the context of metabolic syndrome.¹⁷ Although fatty liver disease is strongly associated with obesity,¹⁸ it is still prevalent in nonobese individuals, especially those of Asian descent.¹⁹ As a consequence of the lack of overall awareness about the condition, fatty liver disease continues to go largely undiagnosed among the general population,²⁰ even among some high-risk populations, like people diagnosed with type 2 diabetes mellitus.²¹ Furthermore, fatty liver disease is asymptomatic until the occurrence of severe complications, making it difficult to identify the disease²⁰ and implement treatment and care interventions, such as lifestyle modification.

Much like the other major public health challenges of the 21st century, fatty liver disease requires systems thinking alongside multidisciplinary and multisectoral responses²² that address the immediate and underlying determinants of the disease. Yet, despite the scale of the challenge posed by fatty liver disease, health system and public health responses have generally been weak and fragmented.^2,23,24 A 2020 study captured data on NAFLD-related policies and guidelines in 102 countries, creating a NAFLD preparedness index that characterized the health system and public health responses in the participating countries. The study found that no country had a written strategy to address the disease and, in most countries, NAFLD was absent within strategies and guidelines for related conditions, including obesity and diabetes.² To fill the dearth of strategic guidance, a consortium of 218 experts from 91 countries recently developed NAFLD consensus statements and recommendations to advance public health and policy agendas.²⁵

Although health systems sit at the center of efforts to address the burden of fatty liver disease, tackling this public health challenge will require action well beyond the health sector. To help the public health community and those across other sectors to conceptualize the design of whole-of-society responses to fatty liver disease, we published a NAFLD–Sustainable Development Goal (SDG) framework.²⁶ The SDGs serve as the mainstay of the 2030 Agenda for Sustainable Development, with clear priorities, from reducing social and economic inequalities to improving nutrition, health, and education, and were adopted by all United Nations member states in 2015. Using the SDGs as a multisectoral framework for action,²⁷ a multidisciplinary group followed a standard Delphi process to identify the targets and indicators that are most relevant to NAFLD, with the final framework including 7 indicators. The framework is intended as a strategic advocacy tool to build the case for closer collaboration within and between sectors, to address fatty liver disease and other NCDs. Similar work has been undertaken to develop a framework to inform policy approaches on sustainable development and urban health²⁸ and to highlight the importance of addressing obesity for achieving the SDG agenda.²⁹

Here, we present the development of the first fatty liver disease–SDG score, covering 195 countries and territories from 1990 to 2017. The fatty liver disease–SDG score builds on the earlier framework to provide a multisectoral lens through which to view country-level preparedness to address the challenge of fatty liver disease, and to guide future health and development sector collaboration and action on this issue.

METHODS

NAFLD Sustainable Development Goal framework

The NAFLD–SDG framework underpinning the fatty liver disease–SDG score was developed through a Delphi process. First, a core team of researchers reviewed the SDG targets and indicators,³⁰ identifying those directly or indirectly associated with NAFLD. Subsequently, a multidisciplinary group of experts (n = 15) was invited to select which of the shortlisted targets and indicators to include in the NAFLD–SDG framework. Targets and indicators with 75% or greater agreement were included in the final NAFLD–SDG framework, with this framework comprising 16 targets and 7 indicators (Figure 1). The detailed methodology has been published.²⁶

FIGURE 1.

NAFLD–SDG framework. The NAFLD–SDG framework shows the SDG targets and indicators that are most relevant to NAFLD. The 8 colored segments indicate the selected targets and the 7 selected indicators are nested within 5 of these targets. Solid lines indicate targets with a direct link to NAFLD and dashed lines show those indirectly related to NAFLD. Abbreviations: NCD, noncommunicable disease; SDG, Sustainable Development Goal.

Development of the fatty liver disease Sustainable Development Goal score

The indicators included in the fatty liver disease–SDG score are shown in Table 1. We developed 2 sets of fatty liver disease–SDG scores. The first set was developed using 6 indicators [child wasting, child overweight, NCD mortality, a universal health coverage (UHC) service coverage index, health worker density, and education attainment] and excluded the urban green space (UGS) score as it was not available for all countries and territories. It covers 195 countries and territories between 1990 and 2017. The second set was constructed using all 7 indicators and includes only the 60 countries for which the UGS data were available in 2017.

TABLE 1.

List of indicators used to develop the fatty liver disease–SDG score

Indicator	Indicator description	Source	Related SDG indicator	Group category
Child overweight	Prevalence of overweight in children aged 2–4 y (%)	GBD 2017	2.2.2	Negative
Child wasting	Prevalence of wasting in children younger than 5 y (%)	GBD 2017	2.2.2	Negative
NCD mortality	Age-standardized death rate due to cardiovascular disease, cancer, type 2 diabetes, and chronic respiratory disease in populations aged 30–70 y, per 100,000 population	GBD 2017	3.4.1	Negative
UHC service coverage index	Coverage of essential health services, as defined by the UHC service coverage index of 9 tracer interventions and risk-standardized death rates or mortality-to-incidence ratios from 32 causes amenable to personal health carea	GBD 2017	3.8.1	Positive
Health worker density	Health worker density per 1000 population, by cadre and summed across cadresb	GBD 2017	3.c.1	Positive
Education	Age-standardized level of educational attainment for all ages 15–99	GBD 2020 preliminary analysis	4.1.2	Positive
UGS score	Logarithm of total vegetation index per capitac	Kwon et al	11.7.1	Positive

^aThirty-two causes amenable to personal health care included tuberculosis, diarrheal diseases, lower respiratory infections, upper respiratory infections, chronic respiratory diseases, diphtheria, whooping cough, tetanus, measles, maternal disorders, neonatal disorders, colon and rectum cancer, nonmelanoma skin cancer, breast cancer, cervical cancer, uterine cancer, testicular cancer, Hodgkin lymphoma, leukemia, rheumatic heart disease, ischemic heart disease, cerebrovascular disease, hypertensive heart disease, peptic ulcer disease, appendicitis, hernia, gallbladder and biliary diseases, epilepsy, diabetes, chronic kidney disease, congenital heart anomalies, and adverse effects of medical treatment.

^bCadres included physicians, nurses, midwives, and pharmacists.

^cUsed the normalized difference vegetation index as a basis for the UGS indicator.

Abbreviations: GBD, Global Burden of Disease; NCD, noncommunicable disease; SDG, Sustainable Development Goal; UGS, urban green space; UHC, universal health coverage.

The estimates for child wasting, child overweight, NCD mortality, the UHC service coverage index, health worker density, and education attainment came from the “Global Burden of Disease (GBD), Injuries, and Risk Factors Study.”^31–33 Details of the input data and modeling procedures for estimating these indicators have been published.³⁴ The data for UGS were extracted from a published study conducted by Kwon et al.³⁵ UGS is a globally comparable metric computed using Sentinel-2 satellite imagery data.³⁶

We took an analytical approach similar to the GBD’s health-related SDG index to develop the fatty liver disease–SDG score. First, indicators were grouped into either a “positive” or “negative” category. The “positive” category consisted of indicators where higher estimates were associated with better health outcomes (eg, UHC service coverage index). The “negative” category consisted of indicators where lower estimates were associated with better health outcomes (eg, child wasting).

Then, all indicators were scaled from 0 to 100, with 0 denoting the worst observed performance and 100 reflecting the best performance, to make them comparable. To reduce the sensitivity of extreme outliers in a given location-year, we set the lower bound at the 2.5th percentile and the upper bound at the 97.5th percentile of the distribution for a given indicator. For “positive” indicators, any value below the 2.5th percentile was assigned a value of 0 and any value exceeding the 97.5th percentile was assigned a value of 100. The “negative” indicators were scaled and adjusted for outliers similarly but with 0 assigned to any value exceeding the 97.5th percentile and 100 assigned to any value below the 2.5th percentile, over the same study period. A modified scaling approach was applied to 2 indicators: NCD mortality and health worker density. Specifically, NCD mortality was scaled in log-space. Health worker density was scaled to reflect the density of each health worker cadre (ie, physicians, nurses, midwives, and pharmacists). The details of the modified scaling approach for health worker density have been published.³⁴

The final fatty liver disease–SDG score was calculated in 2 steps. First, we computed the geometric mean of child wasting and child overweight, 2 indicators that fall under the same SDG target.³⁴ Then, we computed the geometric mean of the remaining indicators, including the aggregate child wasting and child overweight score. In both steps, we restricted draws of each indicator score to a minimum value of 1 before computing the geometric mean to mitigate issues with values close to 0. To generate the fatty liver disease–SDG score for the 7 standard GBD super-regions,³⁷ we aggregated the national-level, unscaled estimates of each indicator for each super-region, using population weights. Then, the national-level 2.5th and 97.5th percentile values for each indicator were applied to scale the indicators for each super-region location, before taking the geometric mean of the indicators, to produce the final fatty liver disease–SDG scores.

Every analytic step was carried out for 1000 draws from the posterior distribution of the previous step, to ensure uncertainty from all inputs, and analyses were propagated through to the final scores. Uncertainty intervals (UIs) were obtained by taking the 2.5th and 97.5th percentiles of the 1000 draw values.

Combining the fatty liver disease Sustainable Development Goal scores with the NAFLD preparedness index

In contrast to our fatty liver disease–SDG score, which aims to measure preparedness to address fatty liver disease from a multisectoral, whole-of-society perspective, the described NAFLD preparedness index² reports on country preparedness to address NAFLD specifically from a health system and public health policy perspective. After the development of the fatty liver disease–SDG scores, we combined them with the NAFLD preparedness index for a more comprehensive assessment of countries’ fatty liver disease preparedness. Fatty liver disease–SDG scores for 100 countries included in the NAFLD preparedness index were extracted and then ranked. Two countries/territories included in the NAFLD preparedness index (Aruba and Hong Kong) were not included in the fatty liver disease–SDG score and, hence, were excluded. For these 100 countries, we summed the country rankings for the fatty liver disease–SDG score with the rankings of the NAFLD preparedness index.

Comparing the fatty liver disease Sustainable Development Goal scores to the NAFLD preparedness index and the Human Development Index

We separately compared the 2017 estimates of fatty liver disease–SDG scores to the NAFLD preparedness index² and the Human Development Index (HDI).³⁸ The HDI is a composite index of life expectancy, level of education attainment, and gross national income per capita that measures the overall human development of a country. It covers some of the themes also captured in the fatty liver disease–SDG score, namely, education; however, it does not incorporate key issues for fatty liver disease, such as UHC service coverage or access to UGSs, which are included in the fatty liver disease–SDG score. Two countries/territories (Aruba and Hong Kong) were excluded from the comparison analysis between fatty liver disease–SDG scores and the NAFLD preparedness index, whereas 7 countries/territories (Hong Kong, Liechtenstein, Palau, Saint Kitts and Nevis, San Marino, Eswatini, and Tuvalu) were excluded for the fatty liver disease–SDG score and HDI comparison.

RESULTS

The fatty liver disease–SDG scores for the 195 countries and territories vary substantially, from 14.6 (95% UI: 8.92 to 19.4) in Niger to 93.5 (91.6 to 95.3) in Japan, with 18 countries scoring > 85 on the 0 to100 scale (Figure 2A; Supplemental Table S1 and S2 http://links.lww.com/HEP/F1000 for country and territory scores from 1990 to 2017). The SD of the fatty liver disease–SDG score across all 195 countries and territories in 2017 is 18.58 and the interquartile range is 26.81. The SD and interquartile range of the fatty liver disease–SDG score by GBD super-region can be found in Supplemental Table S3 (http://links.lww.com/HEP/F1000).

FIGURE 2.

Geographical distribution of the fatty liver disease–SDG score, 2017. (A) Fatty liver disease SDG score in 195 countries and territories developed by using 6 indicators (child wasting, child overweight, NCD mortality, a UHC service coverage index, health worker density, and education attainment). (B) Fatty liver disease–SDG score in 60 countries and territories developed by using the 6 aforementioned indicators plus the UGS indicator. Countries and territories with no color indicate that they do not have UGS data. (C) Percentage change (%) of the fatty liver disease–SDG score with and without the UGS indicator in 60 countries that have UGS data. Percent change was calculated by first subtracting the fatty liver disease–SDG score developed without UGS data from the fatty liver disease–SDG score developed with UGS data and then dividing the difference by the fatty liver disease–SDG score without UGS data. Countries and territories with no color indicate that they do not have UGS data. Abbreviations: NCD, noncommunicable disease; SDG, Sustainable Development Goal; UGS, urban green space; UHC, universal health coverage.

Regionally, the high-income super-region had the highest score at 88.8 (95% UI: 87.3 to 90.1) in 2017, and south Asia had the lowest score at 44.1 (42.4 to 45.8). Between 1990 and 2017, the fatty liver disease–SDG score improved in all 7 super-regions, with the percentage increase ranging from 13.3% to 181.2% (Figure 3). The greatest improvement was in south Asia, despite its poor performance in absolute terms.

FIGURE 3.

Temporal trend of the fatty liver disease–SDG score by GBD super-region, 1990 to 2017. Fatty liver disease–SDG score ranges from 0 to 100. The lines represent the population-weighted average of scores for countries and territories within each super-region. Abbreviations: GBD, Global Burden of Disease; SDG, Sustainable Development Goal.

Across the 195 countries and territories, the fatty liver disease–SDG score decreased (worsened) in 8 countries and territories during the study period, with the largest decrease in Guam [–27.9% (95% UI: –32.8 to –20.2)] (Supplemental Table S4 http://links.lww.com/HEP/F1000). In contrast, the biggest fatty liver disease–SDG score increase (improvement) was observed in Eritrea [1116.1% (531.3 to 1913.1)], followed by Ethiopia [645.9% (382.6 to 764.9)] and Laos [628.3% (324.0 to 1292.3)].

Of the 6 indicators that were used to develop the fatty liver disease–SDG score, the UHC service coverage index had the lowest average scaled value across all 195 countries and territories. This was consistent when restricted to the countries and territories with the bottom 20% of the fatty liver disease–SDG scores. The second lowest indicator, however, differed in those 2 groups. When compared across all 195 countries and territories, the indicator with the second lowest scaled value was NCD mortality, whereas, when restricted to the bottom 20%, the second lowest was education attainment.

For the 60 countries and territories where UGS data were available (Figure 2B, Supplemental Table S5 http://links.lww.com/HEP/F1000), the inclusion of the indicators had variable impacts on the fatty liver disease–SDG scores (Figure 2C). In 21 countries and territories (35%), the inclusion of UGS data improved the score, whereas in 39 countries and territories (65%), the score worsened with the inclusion of this indicator. The average percentage improvement in the score including UGS data was 2.62% (95% UI: 0.83 to 3.82), whereas the average decrease was 9.29% (7.04 to 11.92) (Figure 2C). Montenegro had the biggest improvement in score with the inclusion of UGS data (8.37%), whereas Bahrain had the largest decrease (51.4%).

Sweden had the highest overall combined rank when comparing the fatty liver disease–SDG score and NAFLD preparedness index (ranked fourth for the fatty liver disease–SDG score and third on the NAFLD preparedness index), whereas Central African Republic had the lowest (ranked 96th for the fatty liver disease–SDG score and joint 71st on the NAFLD preparedness index). Sweden, the UK, Belgium, Germany, and Israel ranked in the top 15 on both indices. The largest difference between the fatty liver disease–SDG score and the NAFLD preparedness index was seen in India, which ranked 88th on the former and first on the latter (Supplemental Table S6 http://links.lww.com/HEP/F1000).

The comparisons of the national fatty liver disease–SDG scores to the NALFD preparedness index and HDI are shown in Figure 4 (Supplemental Tables S7 and S8 http://links.lww.com/HEP/F1000). Although many countries across all 7 GBD super-regions had near zero NAFLD preparedness index values, countries with higher fatty liver disease–SDG scores were more likely to score higher on the NAFLD preparedness index. A few notable exceptions were found. India and Bulgaria, 2 countries with suboptimal fatty liver disease–SDG scores, had some of the highest NAFLD preparedness index values. The correlation was higher, but not 100%, between the fatty liver disease–SDG score and the HDI.

FIGURE 4.

Comparisons of the fatty liver disease–SDG score to the (A) NAFLD preparedness index and (B) HDI by GBD super-region. The fatty liver disease–SDG score, NAFLD preparedness index, and HDI range from 0 to 100. The dots represent the population-weighted average of scores for countries and territories within each super-region. Abbreviations: GBD, Global Burden of Disease; HDI, Human Development Index; SDG, Sustainable Development Goal.

DISCUSSION

There have been increasingly frequent calls to focus on systems thinking and to develop new tools to conceptualize and implement the complex responses needed to address today’s major health challenges,²² including the partnerships and collaborations that sit at the center of systems responses. In this study, we present a score for 195 countries and territories (1990–2017), which uses the SDG framework as a lens through which to assess countries’ preparedness to tackle fatty liver disease. The burden of fatty liver disease is high³ and rapidly increasing,³⁹ and it is already the fastest growing cause of HCC in France, the UK, and the USA. The incidence of NAFLD-related HCC is projected to increase dramatically by 2030, with increases of 82%, 117%, and 122% from 2016 in China, France, and the USA, respectively.⁴⁰ Fatty liver disease is an archetypical public health issue of the 21st century, requiring action across a wide range of sectors and disciplines. Although the focus of this study was fatty liver disease, the findings have broader relevance to NCDs, especially to closely related conditions, such as type 2 diabetes mellitus, cardiovascular disease, and obesity.

We suggest the fatty liver disease–SDG score for 3 primary uses. Given the lack of awareness about fatty liver disease and the importance of a multisectoral approach in tackling this public health challenge, the score can help to create awareness among key stakeholder groups, within and beyond the health sector. Second, the score can be an advocacy tool for public health professionals, civil society, and patient groups to advocate for greater action across sectors on this neglected public health challenge, at national and global levels. Finally, the score can inform the strategic decision-making within the national, regional, and global liver and other NCD organizations about the types of cross-sectoral actors that they should be engaging and collaborating with. While there is some correlation between the fatty liver disease–SDG score and existing scores, such as the HDI, the new score provides a more granular focus on the key issues impacting fatty liver disease and will support more nuanced discussions at a strategic and policy level. If the score is updated periodically (eg, every 3–5 years), advocates can also use it to scrutinize success and challenges over time, including policy changes. The fatty liver disease–SDG score provides a holistic multisectoral lens, through which to view efforts to address fatty liver disease, complementing existing efforts, such as the NAFLD preparedness index, which takes a focused look at health system and public health responses within countries. Furthermore, the data used to calculate the score are regularly and consistently collected for 195 countries and territories, while the preparedness index had data from only 102 countries.²

As expected, high-income countries generally had higher fatty liver disease–SDG scores than low-income and lower middle-income countries. There were some notable exceptions, including Uruguay, Brunei, and Qatar, none of which scored in the top quartile. This highlights that advanced economic development is not a guarantee of a higher fatty liver disease–SDG score, emphasizing the importance of focused policy interventions aimed at addressing the underlying and direct drivers of public health. These may, for example, target inadequate nutrition and sedentary lifestyles at the population level.⁴¹ Although fatty liver disease is a pressing public health problem, no country is yet fully prepared to address it.²⁵ Geographically, sub-Saharan Africa and south Asia were the GDB super-regions with the lowest scores; however, some countries in these regions performed well overall, such as Cabo Verde and Botswana, which both ranked higher than other more economically advanced countries, highlighting that low- and middle-income countries can take strides in preparing to address conditions such as fatty liver disease.

For the 60 countries where UGS data were available, the inclusion of this indicator had varying impacts on the overall score, improving it in just over one-third of countries and reducing it in the remainder, in the case of Bahrain by over 50%. Although we were unable to include UGS data in the score for all countries and territories, we believe that this indicator captures critical information on the environment in which people live. Importantly, the availability of UGS does not guarantee access and utilization, 2 points that are not reflected in our score. The use of UGS is impacted by socioeconomic and sociocultural factors,^42,43 and efforts to increase its availability need to be accompanied by interventions to increase access and use, such as improved security and lighting. This is especially important among those who can benefit the most from using such space, including people at a higher risk of fatty liver disease and other NCDs, considering that UGS has effects on both physical and mental health.

Whole-of-society and health system responses

We combined the ranking of countries and territories on the fatty liver disease–SDG score with a published NAFLD preparedness index.² While the fatty liver disease–SDG score provides a multisectoral perspective that speaks to a country’s action on fatty liver disease and NCDs more broadly, the NAFLD preparedness index gives insights into the relevant health system policy, guidelines, and strategies that are in place to address NAFLD. By comparing how well countries performed across both indices, we aimed to provide a holistic view of a country’s preparedness to address this public health challenge. Countries that rank highly on both the fatty liver disease–SDG and NAFLD preparedness indices are best prepared to address the challenge of fatty liver disease. The NAFLD preparedness index found substantial variation between countries’ readiness to address NAFLD. Notably, even those countries that score relatively highly exhibit deficiencies in key domains, suggesting that structural changes are needed to optimize NAFLD management and ensure that effective public health approaches are in place.⁴² Further detailed analysis at the regional level of countries and territories ranking highly on both indices could provide useful case studies to understand the policy measures that have been implemented and how these could be implemented in other national or subnational contexts.

Informing national responses to fatty liver disease

While national development priorities vary, fatty liver disease and NCDs—more broadly—are important considerations for decision-makers in all countries. For example, in low-income and lower middle–income countries, where public health issues have traditionally focused on communicable diseases, NCDs are becoming a major cause of morbidity and mortality,^44,45 with important implications for individual health, health systems, and economic development.^46,47

Fatty liver disease, to date, is not addressed in global health policy or technical guidance. Improving public health is a central pillar of the SDG agenda⁴⁸ and should be a primary goal in all countries as a means of driving economic and social progress. While health system preparedness, underpinned by achieving UHC and health equity, is crucial, the underlying causes of fatty liver disease and other highly prevalent diseases cannot be addressed in the health sector alone. Our findings re-emphasize the longstanding calls for health in all policies’ approaches.

Several indicators in this fatty liver disease–SDG score, namely, education attainment and UGS, fall beyond the direct scope of the public health community, pointing to the need to engage across various sectors, and for the public health community to support and champion the work of other sectors. Successful multisectoral action requires strong governance mechanisms that enable different stakeholders to collaborate around shared goals. Such governance structures are frequently missing or insufficient, especially in low- and middle-income countries, where institutions are commonly weak and fragmentation is common.⁴⁹ More detailed analysis is still needed to understand how multisectoral action can best work in practice.

Limitations

This study has several limitations. There is variation in the clinical definition of fatty liver disease and countries may monitor the disease using different methods. Hence, the full burden and impact of the disease are unknown, precluding the potential to externally validate the fatty liver disease–SDG score using the estimated disease burden of fatty liver disease and NASH in each country. While such a validation would theoretically show if high-scoring countries have a lower disease burden and vice versa, interpretation of such an analysis is challenging, in part because primary data on fatty liver disease prevalence are scant and heterogeneous. Changes in fatty liver disease epidemiology occur slowly over time; in theory, the fatty liver disease–SDG scores for 1990, 2000, and 2010 will provide useful insights into the disease burden today, yet the myriad of confounding factors and data quality over this time makes such comparisons fraught.

Furthermore, we recognize that our combination of the fatty liver disease–SDG score with the NAFLD preparedness index uses data from different timepoints, with the former using data from 2017—the latest available data—and the latter from 2020. However, we suggest that it is unlikely that the fatty liver disease–SDG score will have changed substantially between these timepoints and find value in the aggregate score.

One SDG indicator (16.1.4: proportion of population that feel safe walking alone around the area they live after dark) was included in the NAFLD–SDG framework;²⁶ however, data for this indicator were unavailable to include in the fatty liver disease–SDG score.³⁰ We note that the metric for UGS was developed using data from only 90 cities within the 60 countries and territories included and may, thus, not be an accurate representation of UGS throughout each country and territory. We also had no information available regarding the quality of UGS scores. For example, there is uncertainty as to whether UGS practically relates to better walkability and ability to perform outdoor exercise, as UGS has different factors for usability not captured in a single metric, including safety and environmental health risks.^50,51

We present a fatty liver disease–SDG score for 195 countries and territories over 3 decades, with the aim of supporting efforts to address the public health challenge of fatty liver disease through a whole-of-society approach. Fatty liver disease remains a high-prevalence, largely unknown, and underaddressed disease, yet one that will have an increasing impact on health, health systems, and economies in the years ahead. The fatty liver disease–SDG score can help support efforts to raise awareness about fatty liver disease and ultimately assist all levels of policy-making processes to address it.

AUTHOR CONTRIBUTIONS

Jeffrey V. Lazarus: conceived the idea for this study and prepared a proposal to IHME with Henry E. Mark. They also prepared the first draft of the manuscript. Hannah Han and M. Ashworth Dirac: led the data collection. Manik Aggarwal, Ali Ahmadi, Fares Alahdab, Motasem Alkhayyat, Sami Almustanyir, Hubert Amu, Tahira Ashraf, Bantalem Tilaye Tilaye Atinafu, Sara Bagherieh, Mainak Bardhan, Diana Fernanda Bejarano Ramirez, Ajay Nagesh Bhat, Vijay Kumar Chattu, Daniela Contreras, Sandra Cortés, Omar B Da’ar, Bardia Danaei, Rupak Desai, M Ashworth Dirac, Haneil Larson Dsouza, Temitope Cyrus Ekundayo, Iman El Sayed, Noha Mousaad Elemam, Sayeh Ezzikouri, Amr Farwati, Farshad Farzadfar, Ginenus Fekadu, Tushar Garg, Mahaveer Golechha, Pouya Goleij, Vivek Kumar Gupta, Adel Hajj Ali, Saeed S Hamid, Harapan Harapan, Simon I Hay, Reza Homayounfar, Salman Hussain, Segun Emmanuel Ibitoye, Nahlah Elkudssiah Ismail, Linda Merin J, Shubha Jayaram, Bijay Mukesh Jeswani, Jost B Jonas, Abel Joseph, Charity Ehimwenma Joshua, Jacek Jerzy Jozwiak, Vidya Kadashetti, Tesfaye K Kanko, Rami S Kantar, Nitin Kapoor, Moien AB Khan, Sang-woong Lee, Yeong Yeh Lee, Lee-Ling Lim, Stephen S Lim, Stefan Lorkowski, Erkin M Mirrakhimov, Awoke Misganaw, Ali H Mokdad, Jibran Sualeh Muhammad, Efrén Murillo-Zamora, Christopher J L Murray, Sreenivas Narasimha Swamy, Zuhair S Natto, Robina Khan Niazi, Bogdan Oancea, In-Hwan Oh, Jagadish Rao Padubidri, Seoyeon Park, Harsh K Patel, Venkata Suresh Patthipati, Simone Perna, Vivek Podder, Sina Rashedi, Jefferson Antonio Buendia Rodriguez, Leonardo Roever, Umar Saeed, Abdallah M Samy, Danish Iltaf Satti, Allen Seylani, Pritik A Shah, Ali Shamekh, Parnian Shobeiri, Jasvinder A Singh, Anna Aleksandrovna Skryabina, Ker-Kan Tan, Nikhil Kenny Thomas, Tommi Juhani Vasankari, Song Wang, Suowen Xu, Chuanhua Yu, and Zhi-Jiang Zhang: provided data or critical feedback on data sources. Ali Ahmadi, Hubert Amu, Akshaya Srikanth Bhagavathula, Daniela Contreras, M Ashworth Dirac, Adel Hajj Ali, Simon I Hay, Bijay Mukesh Jeswani, Sang-woong Lee, Ali H Mokdad, Christopher J L Murray, Seoyeon Park, Umar Saeed, Abdallah M Samy, and Theo Vos: developed methods or computational machinery. Amirali Aali, Mohsen Abbasi-Kangevari, Eman Abu-Gharbieh, Manik Aggarwal, Bright Opoku Ahinkorah, Ali Ahmadi, Fares Alahdab, Sami Almustanyir, Hubert Amu, Amir Anoushiravani, Sina Azadnajafabad, Sara Bagherieh, Mainak Bardhan, Diana Fernanda Bejarano Ramirez, Akshaya Srikanth Bhagavathula, Ajay Nagesh Bhat, Mariah Malak Bilalaga, Antonio Biondi, Saeid Bitaraf, Srinivasa Rao Bolla, Daniela Calina, Vijay Kumar Chattu, Sandra Cortés, Omar B Da’ar, Bardia Danaei, Rupak Desai, M Ashworth Dirac, Deepa Dongarwar, Haneil Larson Dsouza, Iman El Sayed, Noha Mousaad Elemam, Mohamed A Elmonem, Aisha Elsharkawy, Sayeh Ezzikouri, Amr Farwati, Florian Fischer, Tushar Garg, Elena S George, Seyyed-Hadi Ghamari, Mohammad Ghasemi Nour, Vivek Kumar Gupta, Parham Habibzadeh, Adel Hajj Ali, Saeed S Hamid, Harapan Harapan, Sanam Hariri, Abbas M Hassan, Simon I Hay, Yuta Hiraike, Reza Homayounfar, Mohammad-Salar Hosseini, Sedighe Hosseini Shabanan, Vivian Chia-rong Hsieh, Junjie Huang, Salman Hussain, Segun Emmanuel Ibitoye, Olayinka Stephen Ilesanmi, Nahlah Elkudssiah Ismail, Chidozie C D Iwu, Linda Merin J, Shubha Jayaram, Bijay Mukesh Jeswani, Jost B Jonas, Abel Joseph, Jacek Jerzy Jozwiak, Ali Kabir, Ali Kabir, Vidya Kadashetti, Tesfaye K Kanko, Rami S Kantar, Nitin Kapoor, Joonas H Kauppila, Moien AB Khan, Min Seo Kim, Carlo La Vecchia, Bagher Larijani, Yeong Yeh Lee, Lee-Ling Lim, Chun-Han Lo, Stefan Lorkowski, Jamal Majidpoor, Mohammad-Reza Malekpour, Yasaman Mansoori, Miquel Martorell, Alexios-Fotios A Mentis, Tuomo J Meretoja, Tomislav Mestrovic, Awoke Misganaw, Abdollah Mohammadian-Hafshejani, Ali H Mokdad, Jibran Sualeh Muhammad, Efrén Murillo-Zamora, Christopher JL Murray, Mukhammad David Naimzada, Sreenivas Narasimha Swamy, Hasan Nassereldine, Zuhair S Natto, Robina Khan Niazi, Virginia Nuñez-Samudio, Bogdan Oancea, Antonio Olivas-Martinez, Jagadish Rao Padubidri, Seoyeon Park, Harsh K Patel, Venkata Suresh Patthipati, Gayatri Pemmasani, Simone Perna, Vivek Podder, Akila Prashant, Pradhum Ram, Indu Ramachandra Rao, Jefferson Antonio Buendia Rodriguez, Leonardo Roever, Gholamreza Roshandel, Umar Saeed, Amirhossein Sahebkar, Soumya Swaroop Sahoo, Abdallah M Samy, Chinmoy Sarkar, Danish Iltaf Satti, Allen Seylani, Elaheh Shaker, Parnian Shobeiri, Seyed Afshin Shorofi, Jasvinder A Singh, Paramdeep Singh, Anna Aleksandrovna Skryabina, Joan B Soriano, Majid Taheri, Ker-Kan Tan, Samar Tharwat, Bereket M Tigabu, Marco Vacante, Rohollah Valizadeh, Tommi Juhani Vasankari, Cong Wang, Song Wang, Nuwan Darshana Wickramasinghe, Mazyar Zahir, and Shira Zelber-Sagi: provided critical feedback on methods or results.

ACKNOWLEDGMENTS

Jeffrey V. Lazarus and Trenton M. White acknowledge support to ISGlobal from the grant CEX2018-000806-S funded by MCIN/AEI/10.13039/501100011033 and the “Generalitat de Catalunya” through the CERCA Program, outside of the submitted work. M. Ashworth Dirac acknowledges support from the Global Public Goods Grant from Bill & Melinda Gates Foundation, outside of the submitted work. Aqeel Ahmad thanks the Deanship of Scientific Research at Shaqra University for supporting this work. Salman Hussain acknowledges support from the Operational Programme Research, Development and Education Project, Postdoc2MUNI (No. CZ.02.2.69/0.0/0.0/18_053/0016952), outside of the submitted work. Virginia Nuñez-Samudio acknowledges support from Panamá’s La Secretaría Nacional de Ciencia, Tecnología e Innovación (Senacyt), as a member of the Sistema Nacional de Investigación (SNI), outside of the submitted work. Jagadish Rao Padubidri acknowledges support from Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal in supporting collaborative research, outside of the submitted work. Abdallah M Samy acknowledges the support from Ain Shams University and the Egyptian Fulbright Mission Program, outside of the submitted work.

The GBD Fatty Liver Disease Sustainable Development Goal Collaborators

Jeffrey V. Lazarus^1,2,3,4, Hannah Han⁵, Henry E. Mark², Saleh A. Alqahtani⁶, Jörn M. Schattenberg⁷, Joan B. Soriano^8,9, Trenton M. White¹, Shira Zelber-Sagi^10,11, M. Ashworth Dirac^5,12, Amirali Aali¹³, Mohsen Abbasi-Kangevari¹⁴, Eman Abu- Gharbieh¹⁵, Osama Abu-Shawer¹⁶, Manik Aggarwal¹⁶, Bright Opoku Ahinkorah¹⁷, Aqeel Ahmad¹⁸, Ali Ahmadi^19,20, Fares Alahdab²¹, Motasem Alkhayyat¹⁶, Sami Almustanyir^22,23, Hubert Amu²⁴, Amir Anoushiravani²⁵, Tahira Ashraf²⁶, Bantalem Tilaye Tilaye Atinafu²⁷, Sina Azadnajafabad¹⁴, Nayereh Baghcheghi²⁸, Sara Bagherieh²⁹, Mainak Bardhan^30,31, Diana Fernanda Bejarano Ramirez^32,33, Akshaya Srikanth Bhagavathula³⁴, Neeraj Bhala^35,36, Ajay Nagesh Bhat³⁷, Mariah Malak Bilalaga³⁷, Antonio Biondi³⁹, Saeid Bitaraf⁴⁰, Srinivasa Rao Bolla⁴¹, Antoine Boustany¹⁶, Daniela Calina⁴², Ismael R. Campos-Nonato⁴³, Vijay, Kumar Chattu^44,45, Sheng-Chia Chung^46,47, Daniela Contreras⁴⁸, Sandra Cortés^49,50, Omar B. Da’ar⁵¹, Omid Dadras^52,53, Xiaochen Dai^5,54, Bardia Danaei⁵⁵, Rupak Desai⁵⁶, Shirin Djalalinia⁵⁷, Deepa Dongarwar⁵⁸, Haneil Larson Dsouza^59,60, Temitope Cyrus Ekundayo⁶¹, Iman El Sayed⁶², Noha Mousaad Elemam⁶³, Mohamed A. Elmonem⁶⁴, Aisha Elsharkawy⁶⁵, Sayeh Ezzikouri⁶⁶, Amr Farwati⁶⁷, Farshad Farzadfar¹⁴, Ginenus Fekadu^68,69, Florian Fischer⁷⁰, Tushar Garg⁷¹, Elena S. George⁷², Seyyed-Hadi Ghamari¹⁴,⁷³, Mohammad Ghasemi Nour⁷⁴, Amit Goel⁷⁵, Mahaveer Golechha⁷⁶, Pouya Goleij⁷⁷, Vivek Kumar Gupta⁷⁸, Parham Habibzadeh⁷⁹, Adel Hajj Ali⁸⁰, Saeed S. Hamid⁸¹, Harapan Harapan⁸², Sanam Hariri^25,83, Maryam Hashemian^25,84 Abbas M. Hassan⁸⁵, Mohammed Bheser Hassen^5,86, Simon I. Hay^5,87, Yuta Hiraike⁸⁸, Reza Homayounfar^89,90, Mohammad-Salar Hosseini⁹¹, Sedighe Hosseini Shabanan⁹², Soodabeh Hoveidamanesh⁹³, Vivian Chia-rong Hsieh⁹⁴, Junjie Huang⁹⁵, Salman Hussain^96,97, Segun Emmanuel Ibitoye⁹⁸, Olayinka Stephen Ilesanmi^99,100, Nahlah Elkudssiah Ismail¹⁰¹, Chidozie CD Iwu¹⁰², Linda Merin J¹⁰³, Elham Jamshidi^104,105, Umesh Jayarajah¹⁰⁶,¹⁰⁷, Shubha Jayaram¹⁰⁸, Bijay ghMukesh Jeswani¹⁰⁹, Jost B. Jonas¹¹⁰,¹¹¹, Abel Joseph¹⁶, Charity Ehimwenma Joshua¹¹², Jacek Jerzy Jozwiak¹¹³, Ali Kabir¹¹⁴, Vidya Kadashetti¹¹⁵, Tesfaye K. Kanko¹¹⁶, Rami S Kantar^117,118, Nitin Kapoor^119,120, Ibraheem M. Karaye¹²¹, Joonas H. Kauppila^122,123, Mohammad Keykhaei^14,124, Moien A.B. Khan^125,126, Min Seo Kim^127,128, Hamid Reza Koohestani¹²⁹, Ambily Kuttikkattu¹³⁰, Carlo La Vecchia¹³¹, Bagher Larijani¹³², Sang-woong Lee¹³³, Yeong Yeh Lee^134,135, Lee-Ling Lim^136,137, Stephen S. Lim^5,54, Chun-Han Lo¹³⁸, Stefan Lorkowski^139,140, Jamal Majidpoor¹⁴¹, Mohammad- Reza Malekpour¹⁴, Yasaman Mansoori¹⁴², Miquel Martorell^143,144, Sahar Masoudi²⁵, Alexios-Fotios A. Mentis¹⁴⁵, Tuomo J. Meretoja^146,147, Tomislav Mestrovic^148,5, Erkin M. Mirrakhimov^149,150, Awoke Misganaw^87,151, Abdollah Mohammadian-Hafshejani¹⁹, Ali H. Mokdad^5,87, Jibran Sualeh Muhammad¹⁵², Efrén Murillo-Zamora^153,154, Christopher J. L. Murray^5,54, Mukhammad David Naimzada^155,156, Sreenivas Narasimha Swamy¹⁵⁷, Hasan Nassereldine⁵, Zuhair S. Natto^158,159, Robina Khan Niazi¹⁶⁰, Virginia Nuñez- Samudio^161,162, Bogdan Oancea¹⁶³, In-Hwan Oh¹⁶⁴, Olubunmi Omotola Oladunjoye¹⁶⁵, Antonio Olivas-Martinez^166,167, Jagadish Rao Padubidri¹⁶⁸, Seoyeon Park, Beng¹⁶⁹, Harsh K. Patel¹⁷⁰, Ronit Patnaik Patnaik¹⁷¹, Venkata Suresh Patthipati^172,173, Gayatri Pemmasani¹⁷⁴, Simone Perna¹⁷⁵, Vivek Podder^176,177, Akram Pourshams²⁵, Akila Prashant¹⁷⁸, Pradhum Ram¹⁷⁹, Indu Ramachandra Rao¹⁸⁰, Sina Rashedi^181,182, Mohammad-Mahdi Rashidi^14,73, Negar Rezaei^14,132, Jefferson Antonio Buendia Rodriguez¹⁸³, Leonardo Roever¹⁸⁴, Gholamreza Roshandel¹⁸⁵, Bahar Saberzadeh- Ardestani¹⁸⁶, Umar Saeed^187,188, Sher Zaman Safi^189,190, Amirhossein Sahebkar^191,192, Soumya Swaroop Sahoo¹⁹³, Mohammad Amin Salehi¹⁹⁴, Abdallah M. Samy^195,196, Senthilkumar Sankararaman^197,198, Chinmoy Sarkar¹⁹⁹, Danish Iltaf Satti²⁰⁰, Allen Seylani²⁰¹, Pritik A. Shah^202,203, Elaheh Shaker^182,204, Ali Shamekh^205,206, Parnian Shobeiri^207,204, Seyed Afshin Shorofi^208,29, Jasvinder A. Singh^210,211, Paramdeep Singh²¹², Md Shahjahan Siraj²¹³, Anna Aleksandrovna Skryabina²¹⁴, Amir Ali Sohrabpour²⁵, Keita Suzuki²¹⁵, Majid Taheri^216,217, Ker-Kan Tan²¹⁸, Samar Tharwat²¹⁹, Nikhil Kenny Thomas²²⁰, Bereket M. Tigabu²²¹, Marco Vacante³⁹, Seyed Mohammad Vahabi¹⁹⁴, Rohollah Valizadeh²²², Tommi Juhani Vasankari^223,224, Theo Vos^5,54, Cong Wang²²⁵, Song Wang²²⁶, Nuwan Darshana Wickramasinghe²²⁷, Suowen Xu^228,229, Chuanhua Yu²³⁰, Ismaeel Yunusa²³¹, Mazyar Zahir²³², Moein Zangiabadian²³³, Zhi-Jiang Zhang²³⁴

¹Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain; ²EASL International Liver Foundation, Geneva, Switzerland; ³Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; ⁴CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA; ⁵Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA; ⁶Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; ⁷Department of Medicine, Metabolic Liver Research Program, University Medical Center, Mainz, Germany; ⁸Respiratory Department, Hospital Universitario de la Princesa; School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; ⁹Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; ¹⁰School of Public Health, University of Haifa, Haifa, Israel; ¹¹Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel; ¹²Department of Health Metrics Sciences, Department of Family Medicine, University of Washington, Seattle, Washington, USA; ¹³Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; ¹⁴Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran; ¹⁵Clinical Sciences Department, University of Sharjah, Sharjah, United Arab Emirates; ¹⁶Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA; ¹⁷School of Public Health, University of Technology Sydney, Sydney, New South Wales, Australia; ¹⁸Department of Medical Biochemistry, Shaqra University, Shaqra, Saudi Arabia; ¹⁹Department of Epidemiology and Biostatistics, Shahrekord University of Medical Sciences, Shahrekord, Iran; ²⁰Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ²¹Mayo Evidence-based Practice Center, Mayo Clinic Foundation for Medical Education and Research, Rochester, Minnesota, USA; ²²College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; ²³Ministry of Health, Riyadh, Saudi Arabia; ²⁴Department of Population and Behavioral Sciences, University of Health and Allied Sciences, Ho, Ghana; ²⁵Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; ²⁶University Institute of Radiological Sciences and Medical Imaging Technology, The University of Lahore, Lahore, Pakistan; ²⁷School of Nursing and Midwifery Science, Debre Berhan University, Debre Berhan, Ethiopia; ²⁸Nursing, Saveh University of Medical Sciences, Saveh, Iran; ²⁹School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; ³⁰Department of Molecular Microbiology and Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India; ³¹Department of Molecular Microbiology, Indian Council of Medical Research, New Delhi, India; ³²Department of Medicine, El Bosque University, Bogota, Colombia; ³³Transplant Service Unit, University Hospital Foundation Santa Fe de Bogotá, Bogota, Colombia; ³⁴Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas, USA; ³⁵Institutes of Applied Health Research and Translational Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK; ³⁶Institute of Applied Health Research, University of Birmingham, Birmingham, UK; ³⁷Department of General Medicine, Manipal Academy of Higher Education, Mangalore, Karnataka, India; ³⁸Department of Clinical Sciences, University of Sharjah, Sharjah, United Arab Emirates; ³⁹Department of General Surgery and Medical- Surgical Specialties, University of Catania, Catania, Italy; ⁴⁰Department of Biostatistics and Epidemiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; ⁴¹Department of Biomedical Sciences, Nazarbayev University, Nur-Sultan City, Kazakhstan; ⁴²Department of Clinical Pharmacy, University of Medicine and Pharmacy, Craiova, Romania; ⁴³Health and Nutrition Research Center, National Institute of Public Health, Cuernavaca, Mexico; ⁴⁴Department of Community Medicine, Datta Meghe Institute of Medical Sciences, Sawangi, Maharashtra, India; ⁴⁵Saveetha Medical College and Hospitals, Saveetha University, Chennai, India; ⁴⁶Department of Health Informatics, University College London, London, UK; ⁴⁷Health Data Research UK, London, UK; ⁴⁸Clinical Epidemiology, National Autonomous University of Mexico, Mexico City, Mexico; ⁴⁹Department of Public Health, Pontifical Catholic University of Chile, Santiago, Chile; ⁵⁰Research Line in Environmental Exposures and Health Effects at Population Level, Centro de Desarrollo Urbano Sustentable (CEDEUS) [Advanced Center for Chronic Diseases (ACCDIS)], Santiago, Chile; ⁵²Department of Health Systems Management, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; ⁵²Section of Global Health and Rehabilitation, Western Norway University of Applied Sciences, Bergen, Norway; ⁵³Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; ⁵⁴Department of Health Metrics Sciences, University of Washington, Seattle, Washington, USA; ⁵⁵Department of Medical Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ⁵⁶Division of Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, Georgis, USA; ⁵⁷Development of Research and Technology Center, Ministry of Health and Medical Education, Tehran, Iran; ⁵⁸Health Science Center, University of Texas, Houston, Texas, USA; ⁵⁹Forensic Medicine and Toxicology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Mangalore, Karnataka, India; ⁶⁰Forensic Medicine and Toxicology, Kasturba Medical College Mangalore, Mangalore, Dakshina Kannada District, Karnataka, India; ⁶¹Department of Biological Sciences, University of Medical Sciences, Ondo, Ondo, Nigeria; ⁶²Biomedical Informatics and Medical Statistics Department, Alexandria University, Alexandria, Egypt; ⁶³Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates; ⁶⁴Egypt Center for Research and Regenerative Medicine (ECRRM), Cairo, Egypt; ⁶⁵Department of Endemic Medicine and Hepatogastroenterology, Cairo University, Cairo, Egypt; ⁶⁶Department of Virology, Pasteur Institute of Morocco, Casablanca, Morocco; ⁶⁷Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar; ⁶⁸School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China; ⁶⁹Department of Pharmacy, Wollega University, Nekemte, Ethiopia; ⁷⁰Institute of Public Health, Charité Medical University Berlin, Berlin, Germany; ⁷¹Department of Radiology, King Edward Memorial Hospital, Mumbai, Maharashtra, India; ⁷²Institute for Physical Activity and Nutrition, Deakin University, Melbourne, Victoria, Australia; ⁷³Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ⁷⁴E-Learning Center, Mashhad University of Medical Sciences, Mashhad, Iran; ⁷⁵Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India; ⁷⁶Department of Health Systems and Policy Research, Indian Institute of Public Health, Gandhinagar, Gujrat, India; ⁷⁷Department of Genetics, Sana Institute of Higher Education, Sari, Iran; ⁷⁸Macquarie University, Sydney, Ne South Wales, Australia; ⁷⁹School of Medicine, University of Maryland, Baltimore, Maryland, USA; ⁸⁰Heart, Vascular, Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; ⁸¹Department of Medicine, Aga Khan University, Karachi, Pakistan; ⁸²Medical Research Unit, Syiah Kuala University, Banda Aceh, Indonesia; ⁸³Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran; ⁸⁴Biology Department, Utica University, Utica, New York, USA; ⁸⁵Department of Plastic Surgery, University of Texas, Houston, Texas, USA; ⁸⁶National Data Management Center for Health (NDMC), Ethiopian Public Health Institute, Addis Ababa, Ethiopia; ⁸⁷Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, Washington, USA; ⁸⁸Division for Health Service Promotion, University of Tokyo, Tokyo, Japan; ⁸⁹Non-communicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran; ⁹⁰National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ⁹¹Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; ⁹²School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; ⁹³Burn Research Center, Shahid Motahari Hospital, Tehran, Iran; ⁹⁴Department of Health Services Administration, China Medical University, Taichung, Taiwan; ⁹⁵Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China; ⁹⁶Czech National Centre for Evidence-Based Healthcare and Knowledge Translation, Masaryk University, Brno, Czech Republic; ⁹⁷Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic; ⁹⁸Department of Health Promotion and Education, University of Ibadan, Ibadan, Nigeria; ⁹⁹Department of Community Medicine, University of Ibadan, Ibadan, Nigeria; ¹⁰⁰Department of Community Medicine, University College Hospital, Ibadan, Ibadan, Nigeria; ¹⁰¹Department of Clinical Pharmacy, MAHSA University, Bandar Saujana Putra, Malaysia; ¹⁰²School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa; ¹⁰³Department of Orthodontics and Dentofacial Orthopedics, Dr. D. Y. Patil University, Pune, Maharashtra, India; ¹⁰⁴Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ¹⁰⁵ Division of Pulmonary Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland; ¹⁰⁶Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka; ¹⁰⁷Department of Surgery, National Hospital, Colombo, Sri Lanka; ¹⁰⁸Department of Biochemistry, Government Medical College, Mysuru, Karnataka, India; ¹⁰⁹Department of Internal Medicine, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujrat, India; ¹¹⁰Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland; ¹¹¹Department of Ophthalmology, Heidelberg University, Mannheim, Germany; ¹¹²Department of Economics, National Open University, Benin City, Nigeria; ¹¹³Department of Family Medicine and Public Health, University of Opole, Opole, Poland; ¹¹⁴Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran; ¹¹⁵Department of Oral and Maxillofacial Pathology, Krishna institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India; ¹¹⁶Department of Biomedical sciences, Arba Minch University, Arba Minch, Ethiopia; ¹¹⁷The Hansjörg Wyss Department of Plastic and Reconstructive Surgery, Nab’a Al-Hayat Foundation for Medical Sciences and Health Care, New York, New York, USA; ¹¹⁸Cleft Lip and Palate Surgery Unit, Global Smile Foundation, Norwood, Massachusetts, USA; ¹¹⁹Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital (CMC), Vellore, Tamil Nadu, India; ¹²⁰Implementation Science Lab, Baker Heart and Diabetes Institute, Melbourne, Australia; ¹²¹School of Health Professions and Human Services, Hofstra University, Hempstead, New York, USA; ¹²²Surgery Research Unit, University of Oulu, Oulu, Finland; ¹²³Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; ¹²⁴Students’ Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran; ¹²⁵Family Medicine Department, United Arab Emirates University, Al Ain, United Arab Emirates; ¹²⁶Primary Care Department, NHS North West London, London, UK; ¹²⁷Department of Genomics and Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Seoul, South Korea; ¹²⁸Public Health Center, Ministry of Health and Welfare, Wando, South Korea; ¹²⁹Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran; ¹³⁰Department of Nephrology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India; ¹³¹Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; ¹³²Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran; ¹³³Pattern Recognition and Machine Learning Lab, Gachon University, Seongnam, South Korea; ¹³⁴Department of Medicine, University of Science Malaysia, Kota Bharu, Malaysia; ¹³⁵School of Medical Sciences, University of Science Malaysia, Kota Bharu, Malaysia; ¹³⁶Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia; ¹³⁷Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Taiwan, China; ¹³⁸Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA; ¹³⁹Institute of Nutritional Sciences, Friedrich Schiller University Jena, Jena, Germany; ¹⁴⁰Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Jena, Germany; ¹⁴²Department of Anatomy, Gonabad University of Medical Sciences, gonabad, Iran; ¹⁴³Shiraz University of Medical Sciences, Shiraz, Iran; ¹⁴⁴Department of Nutrition and Dietetics, University of Concepcion, Concepción, Chile; ¹⁴⁴Centre for Healthy Living, University of Concepción, Concepción, Chile; ¹⁴⁵International Dx Department, BGI Genomics, Copenhagen, Denmark; ¹⁴⁶Breast Surgery Unit, Helsinki University Hospital, Helsinki, Finland; ¹⁴⁷University of Helsinki, Helsinki, Finland; ¹⁴⁸University Centre Varazdin, University North, Varazdin, Croatia; ¹⁴⁹Internal Medicine Program, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan; ¹⁵⁰Department of Atherosclerosis and Coronary Heart Disease, National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan; ¹⁵¹National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia; ¹⁵²Department of Basic Medical Sciences, University of Sharjah, Sharjah, United Arab Emirates; ¹⁵³Clinical Epidemiology Research Unit, Mexican Institute of Social Security, Villa de Alvarez, Mexico; ¹⁵⁴Postgraduate in Medical Sciences, Universidad de Colima, Colima, Mexico; ¹⁵⁵Laboratory of Public Health Indicators Analysis and Health Digitalization, Moscow Institute of Physics and Technology, Dolgoprudny, Russia; ¹⁵⁶Experimental Surgery and Oncology Laboratory, Kursk State Medical University, Kursk, Russia; ¹⁵⁷Mysore Medical College and Research Institute, Government Medical College, Mysore, Karnataka, India; ¹⁵⁸Department of Dental Public Health, King Abdulaziz University, Jeddah, Saudi Arabia; ¹⁵⁹Department of Health Policy and Oral Epidemiology, Harvard University, Boston, Massachusetts, USA; ¹⁶⁰International Islamic University Islamabad, Islamabad, Pakistan; ¹⁶¹Unit of Microbiology and Public Health, Institute of Medical Sciences, Las Tablas, Panama; ¹⁶²Department of Public Health, Ministry of Health, Herrera, Panama; ¹⁶³Department of Applied Economics and Quantitative Analysis, University of Bucharest, Bucharest, Romania; ¹⁶⁴Department of Preventive Medicine, Kyung Hee University, Dongdaemun- gu, South Korea; ¹⁶⁵Department of General Internal Medicine, Baylor College of Medicine, Houston, Florida, USA; ¹⁶⁶Department of Medicine, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Tlalpan, Mexico; ¹⁶⁷Department of Biostatistics, University of Washington, Seattle, Washington, USA; ¹⁶⁸Department of Forensic Medicine and Toxicology, Kasturba Medical College, Mangalore, Karnataka, India; ¹⁶⁹Yonsei University College of Medicine, Yonsei University, Seodaemun-gu, South Korea; ¹⁷⁰Department of Internal Medicine, Ochsner Medical Center, New Orleans, Los Angeles, Califonia, USA; ¹⁷¹Department of General Surgery, University of Texas, Seattle, Washington, USA; ¹⁷²Department of Internal Medicine, Advent Health, Palm coast, Florida, USA; ¹⁷³Department of Hospital Medicine, Sound Physicians, Palm Coast, USA; ¹⁷⁴Department of Medicine, State University of New York, Syracuse, New York, USA; ¹⁷⁵Department of Biology, University of Bahrain, Sakir, Bahrain; ¹⁷⁶Medical College, Tairunnessa Memorial Medical College and Hospital, Gazipur, Bangladesh; ¹⁷⁷School of Public Health, University of Adelaide, Adelaide, South Australia, Australia; ¹⁷⁸Department of Biochemistry, Jagadguru Sri Shivarathreeswara University, Mysuru, Karnataka, India; ¹⁷⁹Department of Cardiology, Emory University, Atlanta, Georgia, USA; ¹⁸⁰Department of Nephrology, Manipal Academy of Higher Education, Manipal, Karnataka, India; ¹⁸¹Department of Cardiology, Tehran University of Medical Sciences, Tehran, Iran; ¹⁸²Department of Epidemiology, Non-Communicable Diseases Research Center (NCDRC), Tehran, Iran; ¹⁸³Deparment of Pharmacology and Toxicology, University of Antioquia, Medellin, Colombia; ¹⁸⁴Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil; ¹⁸⁵Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran; ¹⁸⁶Department of Gastroenterology, Tehran University of Medical Sciences, Terhan, Iran; ¹⁸⁷School of Health Sciences, Foundation University, Islamabad, Pakistan; ¹⁸⁸International Center of Medical Sciences Research (ICMSR), Islamabad, Pakistan; ¹⁸⁹Bioscience and Nursing, MAHSA University, Selangor, Malaysia; ¹⁹⁰Interdisciplinary Research Centre in Biomedical Materials (IRCBM), COMSATS Institute of Information Technology, Lahore, Pakistan; ¹⁹¹Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; ¹⁹²Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; ¹⁹³Department of Community and Family Medicine, All India Institute of Medical Sciences, Bathinda, Punjab, India; ¹⁹⁴Department of Medicine, Tehran University of Medical Sciences, Tehran, Iran; ¹⁹⁵Department of Entomology, Ain Shams University, Cairo, Egypt; ¹⁹⁶Medical Ain Shams Research Institute, Ain Shams University, Cairo, Egypt; ¹⁹⁷Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA; ¹⁹⁸Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA; ¹⁹⁹Department of Urban Planning and Design, University of Hong Kong, Hong Kong, China; ²⁰⁰Department of Medicine, Shifa College of Medicine, Shifa Tameer-e-millat University, Islamabad, Pakistan; ²⁰¹National Heart, Lung, and Blood Institute, National Institute of Health, Rockville, Maryland, USA; ²⁰²Department of Infectious Diseases and Microbiology, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India; ²⁰³HepatoPancreatoBiliary Surgery and Liver Transplant Unit, HealthCare Global Limited Cancer Care Hospital, Bangalore, Karnataka, India; ²⁰⁴Tehran University of Medical Sciences, Tehran, Iran; ²⁰⁵Department of Basic Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; ²⁰⁶Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran; ²⁰⁷Department of International Studies, Non-Communicable Diseases Research Center (NCDRC), Tehran, Iran; ²⁰⁸Department of Medical-Surgical Nursing, Mazandaran University of Medical Sciences, Sari, Iran; ²⁰⁹Department of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia; ²¹⁰School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; ²¹¹Department of Medicine Service, US Department of Veterans Affairs (VA), Birmingham, Alabama, USA; ²¹²Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India; ²¹³Maternal and Child Health Division, International Centre for Diarrheal Disease Research, Dhaka, Bangladesh; ²¹⁴Department of Infectious Diseases and Epidemiology, Pirogov Russian National Research Medical University, Moscow, Russia; ²¹⁵Department of Hygiene and Public Health, Kanazawa University, Kanazawa, Japan; ²¹⁶Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran; ²¹⁷Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ²¹⁸Department of Surgery, National University of Singapore, Singapore, Singapore; ²¹⁹Rheumatology and Immunology Unit, Mansoura University, Mansoura, Egypt; ²²⁰Department of Gastroenterology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India; ²²¹Department of Pharmacy, Komar University of Science and Technology, Sulaymaniyah, Iraq; ²²²Urmia University of Medical Sciences, Urmia, Iran; ²²³UKK Institute, Tampere, Finland; ²²⁴Tampere University, Tampere, Finland; ²²⁶⁵Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA; ²²⁶Department of Gastroenterology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China; ²²⁷Department of community Medicine, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka; ²²⁸Department of Endocrinology, University of Science and Technology of China, Hefei, China; ²²⁹Department of Medicine, University of Rochester, Rochester, New York, USA; ²³⁰Department of Epidemiology and Biostatistics, Wuhan University, Wuhan, China; ²³¹Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, South Carolina, USA; ²³²Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ²³³School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; ²³⁴School of Medicine, Wuhan University, Wuhan, China

FUNDING INFORMATION

This work was supported by the EASL International Liver Foundation, which acknowledges funding from Intercept Pharmaceutics, as well as Bristol Myers Squibb and Merck Sharp and Dohme. The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to the data in the study and had final responsibility for the decision to submit to publication.

CONFLICTS OF INTEREST

Jeffrey V. Lazarus reports grants from Gilead Sciences and Roche and consulting fees and advisory arrangements from AbbVie, Gilead Sciences, and Roche, outside the submitted work. Jörn M. Schattenberg reports consulting fees from Apollo Endosurgery, AGED diagnostics, Bayer, Boehringer Ingelheim, Gilead Sciences, GSK, Intercept Pharmaceuticals, Ipsen, Inventiva Pharma, Madrigal, MSD, Northsea Therapeutics, Novartis, Novo Nordisk, Pfizer, Roche, Sanofi, and Siemens Healthineers, speaker fees from Boehringer Ingelheim, Echosens, MedPublico GmbH, Novo Nordisk, Madrigal Pharmaceuticals, and Histoindex, and grants from Gilead Sciences, Boehringer Ingelheim, and Siemens Healthcare GmbH, outside the submitted work. Hannah Han and M. Ashworth Dirac report support for the present manuscript from the EASL International Liver Foundation. Sandra Cortés reports support from the Fondo de Financiamiento de Centros de Investigacion en Areas Prioritarias (FONDAP) (grant number 15130011), outside the submitted work. Xiaochen Dai reports support for the present manuscript from IHME/UW as a salaried employee. Temitope Cyrus Ekundayo reports grants or contracts from The African-German Network of Excellence in Science (AGNES), the Federal Ministry of Education and Research (BMBF), and the Alexander von Humboldt Foundation (AvH) for financial support, outside the submitted work. Vivek Kumar Gupta reports grants or contracts from the National Health and Medical Research Council (NHMRC), Australia, outside the submitted work. Vivian Chia-rong Hsieh reports support from the National Science and Technology Council, Taiwan for Grant # MOST 107-2314-B-039-065-MY3 and grants or contracts from the National Science and Technology Council, Taiwan for Grant # MOST 107-2314-B-039-065-MY3, outside the submitted work. Nahlah Elkudssiah Ismail reports leadership or fiduciary roles in board, society, committee, or advocacy groups, paid or unpaid, with the Malaysian Academy of Pharmacy as council member, outside the submitted work. Abel Joseph reports support from the Bill and Melinda Gates Foundation, grants or contracts from the American College of Gastroenterology for a Clinical Research Award, and support for attending meetings and/or travel from American College of Gastroenterology Annual Meeting 2022, outside the submitted work. Jacek Jerzy Jozwiak reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from NOVART and ADAMED, outside the submitted work. Ibraheem M. Karaye reports support for attending meetings and/or travel from Hofstra University, outside the submitted work. Yeong Yeh Lee reports grants or contracts from NAFLD-related Clinical Trial Investigator for Novo Nordisk and Boehringer Ingelheim and leadership or fiduciary roles in board, society, committee, or advocacy groups, paid or unpaid, with the Malaysian Society of Gastroenterology and Hepatology as President, outside the submitted work. Lee-Ling Lim reports grants or contracts from Boehringer Ingelheim, AstraZeneca, and Abbott Nutrition, outside the submitted work. Stefan Lorkowski acknowledges funding by the German Federal Ministry of Education and Research (nutriCARD, grant agreement number 01EA1808A), grants or contracts from Akcea Therapeutics Germany, consulting fees from Danone, Novartis Pharma, and Swedish Orphan Biovitrum (SOBI), payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Akcea Therapeutics Germany, AMARIN Germany, AMARIN Germany, AMGEN, Berlin-Chemie, Boehringer Ingelheim Pharma, Daiichi Sankyo Deutschland, Danone, Hubert Burda Media Holding, Janssen-Cilag, Lilly Deutschland, Novartis Pharma, Novo Nordisk Pharma, Roche Pharma, Sanofi-Aventis, and SYNLAB Holding Deutschland & SYNLAB Akademie, support for attending meetings and/or travel from AMGEN and Novo Nordisk Pharma., and participation on a Data Safety Monitoring Board or Advisory Board with Akcea Therapeutics Germany, AMGEN, Daiichi Sankyo Deutschland, Novartis Pharma, and Sanofi-Aventis, outside the submitted work. Chinmoy Sarkar reports grants or contracts from the US National Academy of Medicine – Hong Kong University International Fellowship in Global Health Leadership (2019-23), outside the submitted work. Pritik A. Shah reports support for the present manuscript from Bangalore Medical College and Research Institute, part of the Rajiv Gandhi University of Health Sciences, outside the submitted work. Jasvinder A. Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two labs Inc., Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, Jupiter Life Science, UBM LLC, Trio Health, Medscape, WebMD, Practice Point communications, and the National Institutes of Health and the American College of Rheumatology, payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Simply Speaking as a member of the speakers' bureau, support for attending meetings and/or travel from the steering committee of OMERACT, participation on a Data Safety Monitoring Board or Advisory Board with FDA Arthritis Advisory Committee, leadership or fiduciary roles in board, society, committee, or advocacy groups, paid or unpaid, with OMERACT as a steering committee member, the Veterans Affairs Rheumatology Field Advisory Committee as Chair, and UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as editor and Director, stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Atyu biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics Inc., Seres Therapeutics, Tonix Pharmaceuticals, and Charlotte’s Web Holdings, Inc, and previously held stock options in Amarin, Viking, and Moderna pharmaceuticals, outside the submitted work. The remaining authors have no conflicts to report.

Supplementary Material

hep-78-911-s001.pdf ^{(1.8MB, pdf)}