NASH Fitness Intervention in Thrombosis Trial (NASHFit)
Phase: NA
Conditions: Liver Diseases, Blood Disorder, Digestive System Disease
Sponsor: Milton S. Hershey Medical Center

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HRP-591 - Protocol for
Human Subject Research
Protocol Title:
NASH Fitness Intervention in Thrombosis (NASHFit) Trial
Principal Investigator:
Name: Jonathan G. Stine MD MSC, FACP
Department: Medicine
Telephone: 717-531-0003 x289478
E-mail Address: jstine@pennstatehealth.psu.edu
Version Date:
5-28-2020
Clinicaltrials.gov Registration #:
NCT03518294
Abbreviations:
AASLD=American Association for the Study of Liver Diseases
ACSM=American College of Sports Medicine
AE=adverse event
BMI=body mass index
CAT=computerized adaptive testing
DVT=deep vein thrombosis
DXA= dual-energy x-ray absorptiometry
FIB-4=Fibrosis-4 index
HCAR= Hershey Center for Applied Research
HR=heart rate
HRQOL=health related quality of life
IHTG=intrahepatic triglyceride
IPM=Institute for Personalized Medicine
IRB=institutional review board
MRI=magnetic resonance imaging
NAFLD=nonalcoholic fatty liver disease
NASH=nonalcoholic steatohepatitis
NASHFit=NASH Fitness Intervention in Thrombosis
PAI=plasminogen activator inhibitor
PAR-Q= Physical Activity Readiness Questionnaire
PDFF= proton density fat fractionation
PE=pulmonary embolus
PI=principal investigator
PMR=Physical Medicine and Rehabilitation
PNPLA3=patatin like phospholipase-3
PROMIS=patient reported outcomes measurement information system

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PVT=portal vein thrombosis
RCT=randomized controlled trial
SNP= single nucleotide polymorphism
TAF= tissue activating factor
tPA= tissue plasminogen activator
US=United States
VTE=venous thromboembolism
VO2 max=maximal oxygen consumption
vWF=vonWillebrand Factor

Page 3 of 27 (V.04/27/2017)
Table of Contents
1.0
Objectives
2.0
Background
3.0
Inclusion and Exclusion Criteria
4.0
Recruitment Methods
5.0
Consent Process and Documentation
6.0
HIPAA Research Authorization and/or Waiver or Alteration of Authorization
7.0
Study Design and Procedures
8.0
Subject Numbers and Statistical Plan
9.0
Confidentiality, Privacy and Data Management
10.0 Data and Safety Monitoring Plan
11.0 Risks
12.0 Potential Benefits to Subjects and Others
13.0 Sharing Results with Subjects
14.0 Subject Stipend (Compensation) and/or Travel Reimbursements
15.0 Economic Burden to Subjects
16.0 Resources Available
17.0 Other Approvals
18.0 Multi-Site Research
19.0 Adverse Event Reporting
20.0 Study Monitoring, Auditing and Inspecting
21.0 Future Undetermined Research: Data and Specimen Banking
22.0 References

Page 4 of 27 (V.04/27/2017)
1.0
Objectives
1.1
Study Objectives
Often comorbid with obesity, nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic
liver disease in the United States affecting 75-100 million adults, of which 15-20 million have the more
severe variant nonalcoholic steatohepatitis (NASH).(1-3)  Conservative estimates project a doubling in
NASH by 2025.(4-6)  The most advanced forms of NAFLD are associated with increased liver-related
mortality and lower overall survival.  The most effective treatment for NAFLD remains adopting healthy
dietary and exercise patterns,(7-14) however NAFLD patients are among the least physically active
individuals.(15)  Predicting exercise behavior on an individual level is highly complex due to differing
motivation, physiologic response to and subjective experience of exercise as well as emerging genetic
evidence.(16, 17)  The human genome and regulation of gene expression is influenced by physical
activity.  Patatin like phospholipase-3 (PNPLA3) rs738409 polymorphism (GG, GC and CC genotypes)
plays a crucial role in the development of NAFLD.(18-24)  The GG genotype is both associated with
advanced NAFLD,(18, 25-27) and predicts response to physical activity.(10, 28)  Patients with NASH have
extensive extrahepatic disease(29) and are hypercoagulable.(30-42)  NASH is a prothrombotic state with
fibrinolytic dysfunction through elevated plasminogen activator inhibitor (PAI-1), an independent risk
factor for venous thromboembolism (VTE).  Consequently, patients with NASH are predisposed to
VTE;(30-32) the risk of portal vein thrombosis (PVT) in NASH is 210% greater than in other liver
disease.(30, 31)  NASH patients are also at increased risk for pulmonary embolism (PE) and deep vein
thrombosis (DVT).  The most advanced forms of NASH have the greatest thrombotic risk.  While studies
observe that change in diet, weight and physical activity patterns improve NASH, it is not clear whether
these lifestyle changes also reduce the elevated clot risk, however, moderate-intensity exercise leads to
improved fibrinolysis in healthy persons.  
Developing an effective treatment modality to lessen thrombotic risk is imperative for this highly
prevalent condition.  In this proposal, we seek to begin a line of work to answer the question “Can
lifestyle changes effectively mitigate the increased risk of VTE in patients with NASH?” focusing initially
on the at-risk population genetically susceptible to advanced disease.   We hypothesize that fibrinolysis
as measured by PAI-1 will be improved with exercise in patients with NASH.  We expect this effect to be
determined by changes in body composition as PAI-1 levels are dependent on adiposity.
1.2
Primary Study Endpoints
The primary outcome of interest is change in fibrinolysis as measured by PAI-1 level immediately
following completion of the exercise and nutritional counseling program.
1.3
Secondary Study Endpoints
Secondary Outcomes are as follows: (1) Change in PAI-1 after 16-week exercise regimen; (2) Change in
other markers of hemostasis [von Willebrand Factor (vWF), P-selection, Protein S, Protein C, Factor VII,
Factor VIII, Fibrinogen, Antithrombin,] after 16-week exercise regimen; (3) Change in PAI-1 stratified by
PNPLA3 genotype after 16-week exercise regimen; (4) Correlation between loss of hepatic fat as
measured by magnetic resonance imaging proton density fat fractionation (MRI-PDFF) and changes in
hemostatic markers after 16-week exercise regimen; (5) Correlation between maximal oxygen
consumption (VO2 max) and hemostatic markers after 16-weeks of exercise; (6) health-related quality of
life (HRQOL) change following exercise intervention
2.0
Background
2.1
Scientific Background and Gaps

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Significance: NAFLD is the leading cause of chronic liver disease in the United States (US). The
epidemic of metabolic disease has reached substantial portions with widespread public health impact.  
Nearly 70% of US adults are overweight or obese.  NAFLD is a spectrum of chronic liver disease that is
often comorbid with obesity.   NASH is the more severe variant of NAFLD, characterized by inflammation
and/or fibrosis.  NAFLD is the leading cause of chronic liver disease in the US affecting 75-100 million
adults (~40% of the adult population); 15-20 million adults have NASH.(1-3)  NAFLD rates are projected
to double by 2025; conservative estimates suggest 30 million individuals will have been diagnosed with
or progressed to NASH.(4-6)
The most advanced forms of NASH are associated with increased liver-related mortality and lower
overall survival.  NASH is staged based on the degree of fibrosis and ranges from stage 0 (no fibrosis) to
stage 4 (cirrhosis).  Patients with simple steatosis (no fibrosis) have a favorable prognosis with a 1-2%
risk of developing cirrhosis over the subsequent 15-20 years.(43, 44)  The risk of progression with NASH
(presence of fibrosis) is much greater with cirrhosis rates of 12% over the eight years following
diagnosis.(43, 44)   NASH with significant
(stage >2) is associated with increased liver-related
mortality and lower overall survival rates due to cardiovascular events and malignancy.(4-6)  
The current standard of care for NAFLD is lifestyle changes through diet and exercise.  The American
College of Sports Medicine (ACSM) recommends all persons participate in >30 minutes of moderate-
intensity physical activity 3-5 times/week and to perform strength training two times/week.(45)  The
mainstay of NASH treatment is lifestyle change through adopting healthy diet and exercise routines,(7-
14) an effect that may be independent of weight loss.(46, 47)  A recent meta-analysis by Katsagoni et
al.(48) comprised of twenty high-quality randomized controlled trials (RCTs) (n=1,043) found a favorable
pooled effect of exercise (improved liver associated enzymes and intrahepatic fat), independent of
dietary counseling, however, it is unknown if exercise improves fibrosis.  The authors found no
discernable difference between aerobic exercise and strength training, however, intensity of training
was associated with different results and moderate-to-high volume intensity resulted in better
response.(48)  Sustainable exercise remains challenging in clinical practice owing to factors that are
often outside the control of the treating physician. NASH patients are among the least physically active
individuals.(15, 49) Only 20% of patients with NASH achieve the recommended daily physical activity
amount and intensity.  NASH patients have greater ratings of perceived exertion at similar exercise
thresholds,(50) lower physical function and lower performance status.(49, 51) A sedentary lifestyle
promotes NASH progression; lower levels of activity are associated with greater intrahepatic fat and
inflammation.(52, 53)
The human genome and regulation of gene expression is influenced by physical activity.  Over time,
humans have become increasingly sedentary and as a consequence, our current genome has become
maladapted resulting in abnormal gene expression and manifestation of chronic disease, including
NASH.(54)  Genes that were once favorable during times of starvation have now become overexpressed
and pathologic resulting in metabolic dysfunction and sarcopenia.(54) Restoration of this perturbed
metabolic homeostasis can be accomplished through habitual exercise in our sedentary culture.(54)   To
date, the expression of thirty plus genes important to chronic inflammation have been found to be
regulated by exercise.(55)  The PNPLA3 rs738409 polymorphism (a missense variant resulting in cytosine
to guanosine substitution which encodes for an isoleucine to methionine substitution at amino acid
position 148) leads to abnormal protein production and subsequent accumulation of triglycerides in the
liver, independent of obesity.(18-21)  PNPLA3 plays a crucial role in NASH development and progression
to cirrhosis via interaction with behavioral risk factors including physical inactivity.(22-24, 56)  And while
PNPLA3 activity is modulated by hyperinsulinemia and carbohydrate deficiency, the effect of exercise on
PNPLA3 gene expression is unknown.
PNPLA3 genotype is associated with advanced NASH and predicts response to physical activity. The
PNPLA3 GG genotype is associated with the most advanced forms of NASH.(18, 25-27)  PNPLA3 predicts

Page 6 of 27 (V.04/27/2017)
response to lifestyle intervention(10, 28) with the greatest benefit being derived by GG
homozygotes.(28) In their RCT of 154 subjects, Shen et al. (10) found GG homozygotes had the greatest
decrease in body weight, body mass index (BMI) and intrahepatic triglyceride (IHTG) even when
adjusting for higher baseline IHTG percentages.  Additionally, compound GC heterozygotes were more
likely than CC homozygotes to experience weight loss, decrease in BMI and reduction in IHTG.  In fact,
for each G allele, a nearly 3% more absolute reduction in IHTG was observed with exercise intervention.
G-allele substitution occurs 40-45% in NAFLD.(19)
NASH is a prothrombotic state with fibrinolytic dysfunction through elevated PAI-1.
Chronic inflammation from hepatic steatosis(34-37) culminates in activation of the coagulation system
and abnormalities in all three phases of hemostasis. (38, 39)  Hemostasis can be broken down into
primary, secondary and tertiary components.(57) Increased platelet activation (primary hemostasis) has
been observed in NASH as have elevated levels of vWF.(39, 40, 58)  Hypercoagulability (secondary
hemostasis) in NASH manifests through increased levels of Factor VIII and fibrinogen.(38, 39)  Levels of
anticoagulants antithrombin and protein C are decreased in NASH, tipping the hemostatic balance
towards clotting.  The most severe prothrombotic imbalance is seen in parallel with the most advanced
disease (including NASH cirrhosis).(38, 39)  
PAI-1 is elevated in NASH while tissue activating factor antigen and tPA are decreased.  This leads to a
chronic state of hypofibrinolysis (tertiary hemostasis).(39) Similar to the Factor VIII-to-Protein C ratio,
PAI-1 correlates histologically with increasing severity of steatohepatitis and fibrosis.(41)  Additionally,
patients with NASH have longer clot lysis times and greater clot density.(58)  Elevated PAI-1 promotes
thrombotic risk and may accelerate liver disease progression due to local tissue ischemia stemming from
intrahepatic thrombi, known as parenchymal extinction.(59) Clinically, the presence of at least one
thrombotic risk factor is associated with a nearly two-fold fibrosis stage increase in NASH, further
supporting the notion of thrombosis and disease progression.(42, 60)
Patients with NASH are predisposed to VTE.  The hemostatic environment in patients with chronic liver
disease is a precarious balance between pro- and anti-thrombotic factors.  Patients with NASH cirrhosis
are at increased risk for thrombosis.  Independent of metabolic comorbidities, liver transplant recipients
with NASH have a 55% greater risk of PVT.  The odds of PVT increase exponentially for high-risk NASH
(age >60 years with diabetes, hypertension and obesity) [OR 2.1 (95% CI 1.6-2.8)].(30-32, 61)  Our
preliminary data [accepted, 2017 American Association for the Study of Liver Diseases (AASLD) Liver
Meeting] documents further coagulation derangement in NASH.  We found the thrombotic state
extends from the portal venous to the systemic circulation as the risk of VTE (PE/DVT) was two and a
half-fold greater in hospitalized patients with NASH cirrhosis, supporting work by Di Mino et al.(33)
PA1-1 modulates fibrinolysis and is an independent risk factor for VTE.  Decreased fibrinolytic activity
is a risk factor for VTE.(62, 63)  PAI-1, which is produced by adipose tissue and consequently elevated in
obesity and NASH and reduced by weight loss,(64) inhibits breakdown of fibrin based clots through
physiologic inhibition of plasminogen activators (e.g. urokinase).  Elevated PAI-1 levels lead to longer
clot lysis times.(65)  Multiple studies have documented PAI-1 to be an independent predictor of PE, DVT
and PVT when adjusting extensively for prothrombotic confounders.(65-67) PAI-1 is one of the stronger
independent risk factors for PVT [OR 6.4 (95% CI 2.5-16.1).(66)  The 4G/5G PAI-1 polymorphism confers
additional risk for VTE.
Moderate-intensity exercise leads to improved fibrinolysis in healthy persons.  Exercise has a favorable
effect on the coagulation system across all three phases of hemostasis.(68-70) Habitual exercise
improves primary hemostasis via endothelial-dependent vasodilation and nitric oxide production leading
to less platelet activation and aggregation.(71)  Moderate intensity exercise improves hemostasis
efficiency by activating fibrinolysis in concert with improving coagulation.(68, 69)  Specifically, chronic
aerobic based training leads to improved fibrinolytic activity in both healthy subjects and those with

Page 7 of 27 (V.04/27/2017)
cardiovascular disease.  This occurs during exercise and persists at rest.(68, 69, 72-75)  Reductions in
PAI-1 following aerobic exercise programs lasting 3-8 months range from 23-37%.(72, 74-76)  When
comparing subjects who are aerobically trained to those who are not, further benefit has been observed
in fibrinolytic activity via skeletal muscle tPA efficiency.(73)  Patients with higher baseline PAI-1
experience the greatest benefit from exercise through both weight and fat loss.(72, 75, 77)
As the obesity epidemic continues to worsen, prevalence rates of NASH are increasing and threaten to
overwhelm the healthcare system.  The most effective treatment for NASH remains exercise however,
predicting which patients will achieve a response to exercise remains more of an art than a science.  
Genetics may play a role with this response and can be used to identify the patients most likely to derive
benefit.  NASH patients have significant extrahepatic disease including thrombotic events.  Despite the
longstanding knowledge that inflammation leads to thrombosis, exercise improves NASH (a thrombotic
state), and chronic aerobic exercise improves fibrinolysis through PAI-1 (independent risk factor for VTE),
the effect of exercise on thrombosis in this at-risk population remains unknown.  We hypothesize that
increased physical activity will decrease hepatic fat and adipose tissue leading to less PAI-1 associated
thrombotic risk.  
2.2
Previous Data
(1) Definition of clinically important thrombotic events in patients with NASH.  Dr. Stine published two
large cross-sectional studies documenting the increased risk of PVT in NASH.(30, 31)  Of the 33,368
subjects who underwent liver transplantation between 2003-2012, 6.3% (n=2,096) had PVT.  12% of
recipients with NASH had PVT compared to 7% in all other etiologies of liver disease (p<0.001), a finding
that remained statistically significant when adjusting for metabolic confounders.  Additionally, liver
transplant recipients with high-risk NASH have even greater risk for PVT at the time of liver
transplantation with prevalence rates of 14%.
(2) Feasibility of administration of Patient Reported Outcomes Measurement Information System
Computerized Adaptive Testing (PROMIS-CAT) to patients with chronic liver disease. Dr. Stine
completed a pilot study of 109 adult liver transplant candidates enrolled over three months. Through
iPad platform, subjects completed the PROMIS-CAT. All subjects completed the PROMIS-CAT (100%
conversion) and average completion times were ~15 minutes.  The results of this pilot are helpful in that
this novel, technologically advanced model is readily completed by subjects with advanced medical
illness.
Of those patients with
PVT, 12.0% had underlying NASH cirrhosis, whereas
7.2% did in the non-PVT group.
(3) Development of an exercise training model. Dr. Stine developed and led a 16-week aerobic exercise
program training both sedentary and moderately active adults to increase their cardiopulmonary fitness
culminating in competition in an amateur sprint triathlon.  Dr. Stine was previously a certified indoor
cycling instructor, team captain and varsity collegiate lightweight rower at Penn State and an elite
amateur triathlete.  He has a Bachelor’s of Science Degree from Penn State in Nutritional Sciences,
awarded with honors in 2005.
(4) Previous principal investigator of a small clinical trial.  Under the mentorship of Dr. Patrick Northup
(collaborator), Dr. Stine studied twelve patients in a RCT enrolling hospitalized subjects with
decompensated cirrhosis and hepatorenal syndrome. Dr. Stine served as principal investigator (PI) and
administrative contact for the study for two years.  The manuscript was recently accepted and published
in Annals of Hepatology.  During this experience, Dr. Stine obtained the skillset necessary to be an
effective PI for clinical trials.
2.3
Study Rationale
Despite the longstanding knowledge that inflammation leads to thrombosis, exercise improves NASH (a
thrombotic state), and chronic aerobic exercise improves fibrinolysis through PAI-1 (independent risk

Page 8 of 27 (V.04/27/2017)
factor for VTE), the effect of exercise on thrombosis in this at-risk population remains unknown.  
Similarly, while exercise is known to influence pro-inflammatory gene expression, modulation of PNPLA3
activity through exercise is unknown.  
3.0
Inclusion and Exclusion Criteria
3.1
Inclusion Criteria
Adults age >=18 or <70 years
Liver biopsy <= 6months prior to enrollment
Biopsy proven NASH(78)
Lack of secondary causes of hepatic fat accumulation:
Significant alcohol consumption (<21 drinks/week for men and <14 drinks/week
for women)
Chronic hepatitis C
Wilson disease
Lipodystrophy
Parenteral nutrition
Long-term use of steatogenic medications (mipomersen, lomitapide,
amiodarone, methotrexate, tamoxifen, corticosteroids)
Monogenic hereditary disorders   
3.2
Exclusion Criteria
>90 minutes/week of at least moderate intensity exercise over the previous three months as
assessed by the Get Active Questionnaire (GAQ).
Pregnancy
BMI <18 or >45 kg/m2(16)
Uncontrolled diabetes (changes in medication dosing over the previous three months or
hemoglobin A1c >9%)(12)
Active cardiac symptoms
Severe medical comorbidities/psychiatric illness
Decompensated cirrhosis (history of esophageal varices, ascites or hepatic encephalopathy)
Cancer with life expectancy <6 months
MRI contraindications (severe claustrophobia, implanted ferrous metal)
Other liver disease (positive hepatitis B surface antigen)
Active weight-loss program participation or weight-loss supplement use
Active substance abuse/smoking
Inability to provide informed consent
Institutionalized/prisoner
Inability to walk > 2 blocks or ¼ mile
Concurrent use of antiplatelet medications excluding aspirin 81 mg once daily as aspirin
Non-English-speaking patients due to unavailability of translators for all visits/sessions  
3.3
Early Withdrawal of Subjects
3.3.1 Criteria for removal from study
Development of severe adverse event
Subject consents to withdrawal
Development of decompensated cirrhosis
Failure to complete two successive weeks of exercise protocol.
o
Any subject who performs <3 sessions in any given week during the 16-week
study period will be required to extend their training by two additional weeks to

Page 9 of 27 (V.04/27/2017)
offset loss of physical conditioning.  The power calculation accounts for
expected study dropout (15-20% in exercise protocols).
3.3.2
Follow-up for withdrawn subjects
This will be an intention to treat analysis and subjects who are withdrawn will be followed at the
same time points as who are enrolled still.  E.g., they will receive a phone call at the completion
point of the 16-week exercise program.
4.0
Recruitment Methods
4.1
Identification of subjects
Potential subjects will be recruited from the surrounding area by a referral basis through both print
marketing (“Dear Doctor” outreach letter) as well as in-person presentations by Dr. Stine.  StudyKIK
(https://studykik.com), an online recruitment service, will be utilized as well on a consultative basis in
order to increase recruitment using a social media platform.  The social media ad is submitted as an
attachment to this protocol. Also, we will be using the Penn State Marketing Department to send
targeted emails through the patient portal to patients that meet the basic study criteria. The email script
is submitted as an attachment to this protocol.
Once potential subjects are referred to Penn State, they will be pre-screened by phone and/or in-person
after their visit in hepatology clinic.  Activity level will be assessed by the GAQ (attached).  StudyFinder
will be utilized.
The phone screen procedure is described in the supplemental attachment.
4.2
Recruitment process
StudyFinder, Penn State email blast through the patient portal and print materials will be utilized.  
StudyKIK will be used as a consultative service.
4.3
Recruitment materials
StudyFinder and print materials will be utilized.  The print materials are recruitment letters to outside
physician practices and also within Penn State as well as the email blast template letter.  StudyKIK will
develop IRB approved recruitment material in concert with Penn State and all IRB requirements.
4.4
Eligibility/screening of subjects N/A
5.0
Consent Process and Documentation
5.1
Consent Process
5.1.1
Obtaining Informed Consent
5.1.1.1 Timing and Location of Consent
Subjects will be invited for initial consultation performed by the study PI.  
Informed consent will take place at this consultation.  Investigators must ensure
that patients are clearly and fully informed about the purpose, potential risks,
and other critical issues regarding clinical studies in which they volunteer to
participate.  Freely given written informed consent must be obtained from every
subject prior to clinical study participation, including informed consent for any
screening procedures conducted to establish subject eligibility for the study. The
rights, safety, and well-being of the study patients are the most important

Page 10 of 27 (V.04/27/2017)
considerations and should prevail over interests of science and society. The
consent process will occur in a private room in the Penn State Hershey Medical
Center General Clinical Research Center (GCRC).  The PI will carefully discuss the
risks and benefits of study participation and review study procedures. The PI will
make it clear that the subject’s standard clinical care will not be affected in any
way through participation or non-participation in the study. All questions will be
answered prior to signing the informed consent document and the subject will
verbalize understanding at the time of consent. The consent process will take
approximately 15 minutes.
5.1.1.2 Coercion or Undue Influence during Consent
Investigators will explain the consent and allow for ample time to read and ask
questions.  Study procedures will be fully explained, voluntariness will be
emphasized as well as the fact that no care will be denied regardless of the
subject’s decision.
5.1.2
Waiver or alteration of the informed consent requirement
Due to the extensive inclusion/exclusion criteria, patients will be asked to provide verbal
consent to allow the study team to review their PHI to determine their eligibility for the study.
5.2
Consent Documentation
5.2.1
Written Documentation of Consent
Informed consent will be provided by a standardized process and informed consent form.
5.2.2
Waiver of Documentation of Consent (Implied consent, Verbal consent, etc.)
A waiver of consent documentation is requested for the phone screen. This is needed to allow
for collection of PHI while screening potential subjects. Full and written consent will be recorded
before any interventions begin.
5.3
Consent – Other Considerations
5.3.1
Non-English Speaking Subjects
Not planned at the time.
5.3.2
Cognitively Impaired Adults
5.3.2.1 Capability of Providing Consent
N/A
5.3.2.2 Adults Unable To Consent
N/A
5.3.2.3 Assent of Adults Unable to Consent
N/A
5.3.3
Subjects who are not yet adults (infants, children, teenagers)
5.3.3.1 Parental Permission
N/A
5.3.3.2 Assent of subjects who are not yet adults
N/A

Page 11 of 27 (V.04/27/2017)
6.0
HIPAA Research Authorization and/or Waiver or Alteration of Authorization
6.1
Authorization and/or Waiver or Alteration of Authorization for the Uses and Disclosures of PHI
Check all that apply:
Not applicable, no identifiable protected health information (PHI) is accessed, used or
disclosed in this study. [Mark all parts of sections 6.2 and 6.3 as not applicable]
Authorization will be obtained and documented as part of the consent process. [If this is the
only box checked, mark sections 6.2 and 6.3 as not applicable]
Partial waiver is requested for recruitment purposes only (Check this box if patients’ medical
records will be accessed to determine eligibility before consent/authorization has been
obtained). [Complete all parts of sections 6.2 and 6.3]
Full waiver is requested for entire research study (e.g., medical record review studies).
[Complete all parts of sections 6.2 and 6.3]
Alteration is requested to waive requirement for written documentation of authorization
(verbal authorization will be obtained). [Complete all parts of sections 6.2 and 6.3]
6.2
Waiver or Alteration of Authorization for the Uses and Disclosures of PHI
6.2.1
Access, use or disclosure of PHI representing no more than a minimal risk to the privacy of the
individual
6.2.1.1 Plan to protect PHI from improper use or disclosure
Information is included in the “Confidentiality, Privacy and Data Management”
section of this protocol.
6.2.1.2 Plan to destroy identifiers or a justification for retaining identifiers
Identifiers will be destroyed per standard Penn State operating protocol after the
required time frame has been met.
6.2.2
Explanation for why the research could not practicably be conducted without access to and
use of PHI
This is a randomized, controlled trial.
6.2.3
Explanation for why the research could not practicably be conducted without the waiver or
alteration of authorization
This is a randomized, controlled trial.
6.3
Waiver or alteration of authorization statements of agreement
Protected health information obtained as part of this research will not be reused or disclosed to any
other person or entity, except as required by law, for authorized oversight of the research study, or for
other permitted uses and disclosures according to federal regulations.
The research team will collect only information essential to the study and in accord with the ‘Minimum
Necessary’ standard (information reasonably necessary to accomplish the objectives of the research)
per federal regulations.

Page 12 of 27 (V.04/27/2017)
Access to the information will be limited, to the greatest extent possible, within the research team. All
disclosures or releases of identifiable information granted under this waiver will be accounted for and
documented.
7.0
Study Design and Procedures
7.1
Study Design
The aims of this research proposal are to better understand the potential for lifestyle interventions to
reduce the elevated clot risk of patients with NASH without needing to take an anticoagulant (e.g.
warfarin, low-molecular weight heparin).  This proposal includes a RCT to determine the efficacy of
supervised exercise on future clot risk. A RCT (n=42) of subjects with NASH will be conducted with a
supervised 16-week moderate intensity aerobic exercise program as the intervention and the effect on
fibrinolysis will be measured by change in PAI-1.
7.2
Study Procedures
Subjects will be invited for initial consultation performed by the study PI.  This will be completed at the
GCRC.  If subjects are not currently in the Penn State system, they will be registered prior to this
consultation through the Penn State Gastroenterology/Hepatology clinic staff (x28-2664 or x4950).  For
all individuals who provide signed, informed consent, the following baseline measures will be
completed:
Comprehensive history and physical examination
Anthropometric assessment [height, weight, BMI calculation]
Physical activity questionnaire (IPAQ)
Urine Pregnancy Test
Nutrition counseling will be provided by a Registered Dietitian (RD) to promote a hypocaloric,
low-fat dietary intake pattern. In the case that Dieticians are unavailable in person, counseling
will be completed by phone or video chat using the Penn State Health-branded Zoom. Food
Frequency Questionnaire (FFQ) will be used to assess their current dietary practices. Individual
caloric needs will be calculated at baseline using the Mifflin St. Jeor equation, providing resting
energy expenditure (REE), multiplied by the appropriate activity factor (AF) to yield total energy
expenditure (TEE). Adjusted body weight (ABW) will be used when the participant’s BMI is equal
to or greater than 30. Five-hundred to 750 calories will be subtracted to promote an
approximate weight loss of 1 pound per week for participants whose BMI classifies as
overweight or obese. Macronutrient distribution will be recommended at 50-60% carbohydrate,
15-20% protein, and 20-30% fat with <10% total calories attributable to saturated fat. A sodium
intake of <2,000 mg daily will be encouraged.
ABW & IBW Calculations:
Use ABW to calculate REE when BMI >/=30
o
ABW calculation:
Males: IBW + 0.38 x (BW – IBW)
Females: IBW + 0.32 x (BW – IBW)
o
IBW calculation:
Males = 106 + 6 x (Ht.(in)-60)
Females = 100 + 5 x (Ht.(in)-60)
REE via Mifflin St. Jeor Equation:
Male: 10(wt. (kg)) + 6.25(ht. (cm)) - 5(age (yr)) + 5 = REE x AF = TEE
Female: 10(wt. (kg)) + 6.25(ht. (cm)) - 5(age (yr)) – 161 = REE x AF = TEE
Activity Factors:
Lifestyle and Physical Activity Level (PAL)

Page 13 of 27 (V.04/27/2017)
               
Creatin
g a Caloric
Deficit for Weight Loss:
Male and Female:
o
TEE - 500 kcals when BMI 25-29.9
o
TEE – 750 kcals when BMI 30-44.9
Fasting laboratory testing (including baseline assessment of the hemostatic system).  Subjects
will be instructed to be fasting for at least nine hours.  The following tests will be performed:
o
Complete blood count
o
Hemoglobin A1c
o
Thromboelastography
o
Insulin level
o
Basic metabolic panel
o
Hepatic panel
o
Lipid panel
o
Ferritin
o
ADAMTS13
o
Plasminogen activator inhibitor one
o
D-dimer
o
VonWillebrand Factor
o
Protein C
o
Protein S
o
Factor VII
o
Factor VIII
o
INR
o
Fibrinogen
o
Antithrombin
o
P-selectin
o
Adiponectin
o
Cytokeratin-18
Calculation of non-invasive markers of fibrosis [NAFLD Fibrosis Score, Fibrosis-4 Index (FIB-4)
Stool sample collection for 16S ribosomal microbiome assessment.  A home stool collection kit
and instructions will be provided to the subject. The kit will be labeled with the subject’s study
code number.
Additional genetic testing for single nucleotide polymorphisms (SNPs) of interest for exercise
response, coagulation or NASH; subjects will not be notified of the results of these tests.
Assessment of hepatic fat content with MRI-PDFF
Baseline electrocardiogram (ECG) to be reviewed by study physicians
HRQOL assessment via the PROMIS-CAT, an individual approach tailored to the health status of
each subject offering significant improvements over the existing fixed length questionnaire
evaluations of HRQOL (e.g. Short Form-36) that have been used almost exclusively in NASH
(http://www.nihpromis.org).(51, 79-90)  PROMIS includes gender- and age-matched normative
data obtained from extensive testing of the U.S. population.  PROMIS will be completed in-
person under the direct supervision of trained study personnel.
The liver biopsy obtained prior to enrollment will be reviewed by the pathology department to
confirm the stage of fibrosis and NASH Activity Score.
Seated work with no option of moving around and little or no strenuous leisure activity
1.4-1.5
Seated work with discretion and requirement to move around but little or no
strenuous leisure activity
1.6-1.7
Standing work (e.g. housework, shop assistant)
1.8-1.9
Significant amounts of sport or strenuous leisure activity (30-60 min four to five times
per week)
+0.3
(increment)
Strenuous work or highly active leisure
2.0-2.4

Page 14 of 27 (V.04/27/2017)
Whole blood will be drawn in the Penn State Hershey GCRC (hours 730a-4p) by trained GCRC nursing or
NASHFit research staff.  Whole blood will be obtained and placed into the following tubes in the
amounts described below [total nine teaspoons (tsp) of blood]:
Three 3mL lavender (EDTA) top tubes (1.8 tsp)
Two 4.5mL green (sodium heparin) top tubes (1.8 tsp)
Three 6mL red top tube (3.6 tsp)
Three 2.7mL blue (sodium citrate) top tubes (1.6 tsp)
Samples will then be delivered by NashFit study personnel to both the Clinical Laboratory for processing
to serum and platelet poor plasma and also to Susie George in the Institute for Personalized Medicine
(IPM) for processing prior to transfer to the Endocrine Core Laboratory.  Samples will be frozen and
picked up from the Clinical Laboratories by IPM staff and brought to the IPM for storage and also the
Genome Sciences and Bioinformatics Core for Taqman assay performance. Coded samples will be
shipped through the IPM to Dr. Andrew D. Patterson, Associate Professor in University Park for
metabolomics analysis. Results will be sent back to the IPM per standard IPM operating procedure.  
Stool samples will be obtained from the subject at home with a home collection kit and mailed directly
from the subject to Dr. Gina Lamandella (collaborator), Assistant Professor of Medicine, Juniata College.  
Stool samples will be processed, analyzed with 16S rRNA testing and stored in Dr. Lamandella’s
laboratory.
Intervention Conditions: The aerobic exercise protocol is adapted from the landmark NASH-exercise
trials by Sullivan et al(91) and Bacchi et al(92) that demonstrated the efficacy of exercise in improving
intrahepatic fat and body composition but did not evaluate the effect on hemostasis and thrombosis
risk. Once subjects have passed screening, they will be randomized 2:1 into either the exercise or control
group respectively (two exercise subjects per one control subject) using a computer-generated
randomized scheme in blocks of six by an independent statistician (Dr. Ming Wang- Public Health
Sciences).
Following their assessment and randomization, subjects will undergo baseline VO2 max testing at the
Penn State Physical Medicine and Rehabilitation (PMR) Research Laboratories under the supervision of
ACSM certified trained fitness professionals and study physicians.  Anthropometric measurements will
be completed at this assessment as well with dual-energy x-ray absorptiometry (DXA) body composition
measurement, waist circumference, hip circumference and skin fold measurement. Following this,
subjects will be given a Fitbit Charge2 with heart rate (HR) monitor along with an instruction form on
how to use dietary log.  Formal instruction on how to use the Fitbit Charge2 will be provided by trained
study staff.  This will include technical support with the Fitbit app that is supported on smartphones, the
Fitbit website and Fitabase, a secure comprehensive data management platform for research studies,
clinical trials and healthcare innovation projects utilized by >400 clinical trials since its inception.  
Participants will be instructed to record their food and beverage intake in a daily food diary through the
Fitbit app and be provided information on how closely their daily food intake met the goals for
macronutrients and energy.
Moderate intensity aerobic exercise: Subjects in the aerobic exercise group will be supervised to
exercise 30 minutes, five times per week at a moderate intensity (HR target corresponding to 45-55% of
their VO2max). Formal exercise instruction and supervision will be provided by ACSM certified fitness
professionals at the Penn State University Fitness Center. Subjects will initiate their exercise program by
walking on a treadmill for 15 minutes at their target HR goal and progressively increase the duration and
frequency until the goal of 30 minutes of moderate intensity exercise five times a week is reached by the
end of the four-week lead-in period.  Subjects will then exercise five times a week under direct
supervision in one of three locations; the Penn State University Fitness Center, the Cancer Center

Page 15 of 27 (V.04/27/2017)
Exercise Medicine Unit or the Hershey Center for Applied Research. Aerobic exercise can be completed
on either the treadmill, exercise bike, rowing machine or the elliptical machine. Subjects will be given
the opportunity to complete these supervised sessions virtually or in-person as described above. If the
subject chooses to complete the strength training sessions virtually, the study EP will schedule and
complete exercise sessions using Penn State HIPPA complaint Zoom. Additional home exercise beyond
the recommended sessions will be assessed by downloading data from the Fitbit Charge2.  Review of
downloaded information will take place once a week.  Any subject who performs <3 sessions in any
given week during the 16-week study period will be required to extend their training by two additional
weeks to offset loss of physical conditioning. They can be extended no longer than 4 weeks.  If subject
misses more than 2 weeks of exercise sessions, they will be discontinued from the study.
Weekly review of dietary logs obtained via self-report through the FitBit application and secure web-
based platform with directed feedback by trained study personnel (nutritionist) will also be provided
either in-person, telephone interview or video chat. Additionally, participants will be given dietary
education forms.   In the event that the subject does not self-report their dietary intake through the
FitBit platform, the 24-hour dietary recall data collection form will be utilized.
Study investigators will perform an interim history and physical examination on a monthly basis during
the exercise protocol. If subject is required to extend protocol, interim history and physical examinations
will continued to be performed on a monthly basis. The subject may complete these either in person or
virtually.
The purpose of the post-exercise program liver biopsy is to observe changes in stage of fibrosis and
NASH Activity Score.  Liver biopsy is the gold standard to stage chronic liver disease from NASH and the
benefit of disease staging and prognostication outweighs the small risk to the subject.  Non-invasive
methods of diseases staging (serologic scoring systems NFS, FIB-4) and ultrasound with elastography
have inferior performance characteristics with much lower sensitivity and specificity and are hindered
by significant inaccuracy with misclassification bias observed in upwards of 25%.(1, 93)  Sub-
randomization is being performed to ensure a representative sample in this small feasibility subgroup
pilot study.
Participants per-
formed nine
different exercises
involving the major
muscle groups on
weight machines
(chest press,
shoulder press,
vertical traction, leg
press, leg exten-
sion, leg curl,
abdominal crunch)
and free weight
(biceps,
abdominal). After a
learning phase,
partici-
pants performed 3
series of 10
repetitions at 70%-
80% 1-RM, with 1
minute of recovery
between series
Control condition (standard of care): Subjects in the control condition will be instructed to continue
their medical care at the discretion of their treating medical professional.  They will be informed to
maintain their current physical activity level.  They will be given information from the American Liver
Foundation to provide a basic understanding of NASH and to reinforce the counseling from their treating
medical professional.  We expect this information may result in a subject choosing to exercise, however,
similar information-only interventions have led to only small effects, which are accounted for in the
sample size calculation.  Weekly phone calls will be performed by study personnel to ensure adherence
to the protocol (no changes in activity).  Subjects will report to Penn State on a monthly basis for
anthropometric assessment in the GCRC to confirm their self-reports and study investigators will
perform an interim history and physical examination at that time. Subjects may choose to complete this
visit in person or virtually using Zoom. Subjects will also be given a Fitbit Charge2HR and downloaded
data review will be performed monthly at study visits visits.  These methods of compliance have
previously been validated.(91)
This study will be a delayed treatment trial.  Subjects randomized to the control condition will be given
five months of fitness center membership to UFC and access to an ACSM certified fitness professional
for training sessions following completion of the study protocol.
Penn State PM&R Research Laboratories: Housed at Hershey Center for Applied Research (HCAR), the
4,500 ft2 facility is comprised of Exercise, Body Composition, Locomotor Training and Gait Laboratories

Page 16 of 27 (V.04/27/2017)
(Director-Dr. Gater, collaborator).  While the available exercise and body composition assessment
equipment totals well over $1,000,000 and includes multiple gait training devices, this study will utilize
the following exercise equipment: Cosmed® K4B2 Portable Metabolic Device and ECG Telemetry system,
ParvoMedics TrueMax® 2400 Metabolic Measurement System, and Quinton Q710 Stress Testing/Resting
ECG System.  Body composition resources include Lunar iDXA® DXA scanner, skinfold and
anthropometric calipers.  
Penn State University Fitness Center: Housed with the Penn State University Conference Center, the
University Fitness Center has a plethora of resources including free weights and cardiovascular
equipment necessary for this protocol.  In addition, group fitness classes, gymnasium, locker room and
shower facilities are available during convenient all-day hours, 7 days a week.  In addition to the
dedicated NASHFit exercise physiologist, there are an additional seven exercise physiologists on staff.  
There are private rooms available for study visits allowing for completion of assessment immediately
before or after an exercise session by trained study personnel.
Follow-up.  Subjects will be seen by a study investigator immediately after the completion of the 16-
week exercise intervention. This will be completed at the Penn State Hershey GCRC and the PM&R
research laboratory.  A focused history and physical exam, anthropometric assessment including DXA
scan, IPAQ, dietary log, cardiopulmonary fitness testing, laboratories, stool sample, MRI-PDFF, PROMIS
and end of study survey will be completed.  A sub-study of ten subjects will be required to complete a
liver biopsy following sub-randomization at the completion of the exercise intervention. Samples
collected for research purposes will be stored per standard SOP requirements of the Pathology
Department. Subjects will be compensated ($25 at baseline, $25 at completion of the exercise regimen,
$100 following liver biopsy obtained at the completion of the exercise regimen if selected). They will
also be allowed to keep their FitBit Charge2 HR. Finally, participants will receive a list of local fitness
facilities available in the area. Twelve weeks after the end of the program, study staff will contact
participants in the exercise arm by phone to complete a follow up questionnaire.
Paired liver biopsy samples (enrollment sample and post-exercise sub randomized sample) will be sent
to a biotechnology company, Reveal Biosciences, to undergo an automated computerized ImageDx
analysis to evaluate the severity of NASH. Samples will be shipped directly from the Pathology (where
they are stored) and they will be de-identified.
Schedule of visits and study protocol assessments
Visit
Initial Assessment
Exercise Instruction
Exercise Program or
Control
End of exercise
program
Day/Week
Day 0
Weeks 0-4
Weeks 5-19
Week 20
Initial comprehensive history and physical exam
X
Focused history and physical exam
X (monthly)
X
Anthropometric assessment
X
X (monthly)
X
Physical activity questionnaire (IPAQ)
X
X (monthly)
X
Dietary Log
X (weekly)
X (weekly)
x
FitBit activity data download
X (weekly)
X (weekly)
X
Cardiopulmonary fitness testing (VO2 max)
X
X
Electrocardiogram (ECG)
X
Laboratories
X
X
Stool sample
X
X
Urine pregnancy testing (if applicable)
X
Genetic testing
X

Page 17 of 27 (V.04/27/2017)
Liver MRI-PDFF
X
X
PROMIS Quality of Life Assessment via iPad (completed
under direct supervision of trained research personnel)
X
X (monthly)
X
DXA body composition testing
X
X
Liver biopsy
X (if sub-
randomized)
7.3
Duration of Participation
20 weeks- please see above table.
8.0
Subject Numbers and Statistical Plan
8.1
Number of Subjects
We expect to enroll 42 subjects.
8.2
Sample size determination
Subjects will be randomized into two treatment groups.  This is an efficient study design with increased
power and is appropriate for the proposed exercise intervention.  The primary outcome will be change
in PAI-1 following a 16-week exercise course.  Secondary outcomes are described above.  Baseline levels
of PAI-1 are between 35-45 ng/mL.(72, 74-76)  Estimates for change in PAI-1 following exercise regimens
of between 3-8 months duration range between 23-37% with >30% reduction only reported in regimens
>6 months long.(72, 74-76)  De Gues et al.(75) found an initial 24.5% reduction as measured at four
months in PAI-1 levels in thirty healthy adults aerobically exercising 2.5 hours per week. We expect the
exercise intervention to result in a 23% reduction (9 ng/dL) in PAI-1.  We expect no change in PAI-1
levels in the control arm.  We conservatively determined power calculations utilizing the standard
deviations in the literature (2.0 for no exercise group and 14.0 for the aerobic exercise group).  We
expect a 15-20% attrition rate;(94) to account for this we will enroll an additional six subjects.  
Based on these assumptions and a 2:1 enrollment ratio with two subjects in the aerobic exercise arm to
every one subject in the standard of care arm, a total study enrollment size of 28 subjects in the aerobic
exercise arm and 14 in the standard of care arm will achieve 80.74% power to detect a difference in
mean PAI-1 at sixteen weeks of at least 9 ng/mL, using a two-sided, two-sample unequal variance t-test
with a significance level (alpha) of 0.05.  A total study enrollment of 42 subjects is planned.
8.3
Statistical methods
Subjects will be compared across multiple important baseline demographic, laboratory, imaging and
histologic data.  Results will be expressed as means with standard deviations.   Chi-squared and Fisher’s
exact test will be used to analyze our categorical endpoints.  Student’s t test and Mann-Whitney Rank
Sum test will be used for secondary analysis of differences in numerical lab data.  Paired t-tests will be
used where appropriate (e.g. comparison of pre- and post-intervention fibrosis parameters such as NFS
or FIB-4 Score). A p value of <0.05 will be significant.  Intention to treat analysis will be performed.  
Analyses will be conducted using SAS version 9.4.  Multivariable regression models will be constructed.
9.0
Confidentiality, Privacy and Data Management
See the Research Data Plan Review Form
10.0 Data and Safety Monitoring Plan
10.1
Periodic evaluation of data
Dr. Thomas Riley (hepatology) will serve as the independent medical monitor for the proposed research
project and will meet with Dr. Stine bi-annually.  Under the mentorship of Dr. Sciamanna, Dr. Stine will
provide oversight for the conduct of the study and collectively we will follow the protocol proposed and
ensure all eligibility criteria and consent requirements are met prior to enrolling a subject.  All study

Page 18 of 27 (V.04/27/2017)
procedures and adverse event (AE) reporting will occur in accordance with the Penn State College of
Medicine IRB approved protocol. These monitoring activities will remain in place until all participants
have completed the intervention.  Dr. Stine will review AEs on a rolling basis and quarterly.  He will
review study enrollment and any early termination of a subject’s participation.  Any issues requiring
study modification or a change in the risk/benefit to a subject will be reported immediately to the IRB.  
A summary of AEs, study progress and protocol modifications will be sent to the IRB for review in the
annual continuing review report.
10.2
Data that are reviewed
Safety data will be reviewed as will untoward events.
10.3
Method of collection of safety information
Case report forms will be utilized for AEs.  Study visits will assess for AEs.  
10.4
Frequency of data collection
Dr. Stine will review AEs on a rolling basis and quarterly.  He will review study enrollment and any early
termination of a subject’s participation.
10.5
Individuals reviewing the data
Dr. Stine and Dr. Riley
10.6
Frequency of review of cumulative data
Quarterly
10.7
Statistical tests
Subjects will be compared in their randomized groups according to SAE occurrence.  Chi-squared and
Fisher’s exact test will be used to analyze our categorical endpoints.  A p value of <0.05 will be
significant.  Intention to treat analysis will be performed.  Analyses will be conducted using SAS version
9.4.
10.8
Suspension of research
If the SAE’s occur at a threshold that is more than expected as determined by the independent medical
monitor, the PI will place on hold further enrollment in the study until review by an independent local
regulatory board composed of a Hepatologist, a Gastroenterologist, and another uninvolved physician
vote unanimously to continue the study with appropriate binding modifications made and approved by
the local IRB.
11.0 Risks
This study is designed to assess the efficacy of exercise in patients with NASH.  The main risks of any exercise
protocol include physical injury (e.g. musculoskeletal), or an adverse cardiovascular event (myocardial infarction).  
All exercise sessions will be monitored by ACSM certified fitness professionals and an available physician will be
available should any injury or cardiovascular event occur.  In addition, there are several other risks related to the
measures of secondary outcomes:
MRI scan:
Discomfort related to claustrophobia from being inside an enclosed space for the MRI scan and loud
banging noise during the study for which temporary hearing loss has been reported (wearing earplugs can
help prevent this).
DXA scan:
Radiation exposure from the DXA scan that is being used to determine body composition

Page 19 of 27 (V.04/27/2017)
Venipuncture (blood draw):
Discomfort associated with removing blood by venipuncture (by needle from a vein) including mild
discomfort and/or a black and blue mark at the site of puncture.
Less common risks of venipucture include a small blood clot, infection or bleeding at the puncture site,
and on rare occasions fainting during the procedure.
Cardiopulmonary Testing:
Maximal oxygen uptake testing involves exercising to exhaustion. Side effects may include, fainting,
chest pains, weakness, vomiting, muscle soreness and headache.
Risk of falling due to increasing speed and incline of the treadmill during exhaustive exercise.
Liver biopsy:(95)
5-20% musculoskeletal pain despite topical and deep anesthetic
<1% risk of
o
Major bleeding
o
Infection
o
<Inadvertent organ puncture (e.g. kidney, lung, gallbladder, colon)
There is also an inherent risk in randomization as subjects are assigned to a study group by chance.  The study
program a subject is assigned to may prove to be less effective or have more side effects than the other study
groups.
Incidental findings discovered through history & physical exam, pregnancy testing, blood draws, cardiopulmonary
testing, imaging (MRI and DXA) and during the exercise protocol will be handled on an individual basis according
to standard medical practice at the discretion of the study PI.  These results will be communicated to not only the
subject but also the subject’s primary care physician and/or the appropriate medical specialist best suited for
further evaluation.
Beyond this, the risks of this study should be minimal to the subjects.  Prior studies in have shown exercise to be
safe in this population.  The risk benefit ratio is minimized in the study design and safety plan.
12.0 Potential Benefits to Subjects and Others
12.1
Potential Benefits to Subjects
Subjects have the possible benefit to improve their overall and liver-specific health with improved
cardiopulmonary fitness.
12.2
Potential Benefits to Others
If the results are as expected, further demonstration of benefit in exercise for NAFLD will allow for
generalization in this widely prevalent condition afflicting 40 percent of the adult US population
13.0 Sharing Results with Subjects
Results will be shared with study subjects upon completion of the study protocol and analysis of the data and
only upon subject written request. Additionally, subjects in the exercise group will receive a summary letter
detailing their results pre and post-exercise intervention.
14.0 Subject Stipend (Compensation) and/or Travel Reimbursements
Subjects will be given a stipend ($25 following completion of the baseline visit, $25 following the week 20 visit,
$25 after submission of stool sample kit within a week of completion of the program, $100 following completion
of the liver biopsy if selected).  They will also be allowed to keep their FitBit Charge2 HR.

Page 20 of 27 (V.04/27/2017)
15.0 Economic Burden to Subjects
15.1
Costs
Travel
15.2
Compensation for research-related injury
It is the policy of the institution to provide neither financial compensation nor free medical treatment
for research-related injury. In the event of injury resulting from this research, medical treatment is
available but will be provided at the usual charge. Costs for the treatment of research-related injuries
will be charged to subjects or their insurance carriers.
16.0 Resources Available
16.1
Facilities and locations
Penn State Physical Medicine & Rehabilitation (PM&R) Research Laboratories: Housed at Hershey
Center for Applied Research (HCAR), the 4,500 ft2 facility is comprised of Exercise, Body Composition,
Locomotor Training and Gait Laboratories (Director-Dr. Gater, collaborator).  While the available
exercise and body composition assessment equipment totals well over $1,000,000 and includes multiple
gait training devices, this study will utilize the following exercise equipment: Cosmed® K4B2 Portable
Metabolic Device and ECG Telemetry system, ParvoMedics TrueMax® 2400 Metabolic Measurement
System, and Quinton Q710 Stress Testing/Resting ECG System.  Body composition resources include
Lunar iDXA® DXA scanner, skinfold and anthropometric calipers.  
Penn State University Fitness Center: Housed with the Penn State University Conference Center, the
University Fitness Center has a plethora of resources including free weights and cardiovascular
equipment necessary for this protocol.  In addition, group fitness classes, gymnasium, locker room and
shower facilities are available during convenient all-day hours, seven days a week.  In addition to the
dedicated NASHFit exercise physiologist, there are an additional seven exercise physiologists on staff.  
There are private rooms available for study visits allowing for completion of assessment immediately
before or after an exercise session by trained study personnel.
16.2
Feasibility of recruiting the required number of subjects
Study team has access to >500 potential subjects of which <10% are required for recruitment
16.3
PI Time devoted to conducting the research
Dr. Stine has 60% of his effort protected for clinical research.
16.4
Availability of medical or psychological resources
N/A
16.5
Process for informing Study Team
Weekly study team meetings will take place on Wednesday mornings from 10-11am.
17.0 Other Approvals
17.1
Other Approvals from External Entities
N/A
17.2
Internal PSU Committee Approvals
Check all that apply:

Page 21 of 27 (V.04/27/2017)
  Anatomic Pathology – Hershey only – Research involves the collection of tissues or use of pathologic
specimens. Upload a copy of HRP-902 - Human Tissue For Research Form on the “Supporting
Documents” page in CATS IRB. This form is available in the CATS IRB Library.  
  Animal Care and Use – All campuses – Human research involves animals and humans or the use of
human tissues in animals
  Biosafety – All campuses – Research involves biohazardous materials (human biological specimens in
a PSU research lab, biological toxins, carcinogens, infectious agents, recombinant viruses or DNA or
gene therapy).
  Clinical Laboratories – Hershey only – Collection, processing and/or storage of extra tubes of body
fluid specimens for research purposes by the Clinical Laboratories; and/or use of body fluids that
had been collected for clinical purposes, but are no longer needed for clinical use. Upload a copy of
HRP-901 - Human Body Fluids for Research Form on the “Supporting Documents” page in CATS IRB.
This form is available in the CATS IRB Library.
  Clinical Research Center (CRC) Advisory Committee – All campuses – Research involves the use of
CRC services in any way.
  Conflict of Interest Review – All campuses – Research has one or more of study team members
indicated as having a financial interest.
  Radiation Safety – Hershey only – Research involves research-related radiation procedures. All
research involving radiation procedures (standard of care and/or research-related) must upload a
copy of HRP-903 - Radiation Review Form on the “Supporting Documents” page in CATS IRB. This
form is available in the CATS IRB Library.
  IND/IDE Audit – All campuses – Research in which the PSU researcher holds the IND or IDE or
intends to hold the IND or IDE.
  Scientific Review – Hershey only – All investigator-written research studies requiring review by the
convened IRB must provide documentation of scientific review with the IRB submission. The
scientific review requirement may be fulfilled by one of the following: (1) external peer-review
process; (2) department/institute scientific review committee; or (3) scientific review by the Clinical
Research Center Advisory committee.  NOTE: Review by the Penn State Hershey Cancer Institute
Scientific Review Committee is required if the study involves cancer prevention studies or cancer
patients, records and/or tissues. For more information about this requirement see the IRB website
at: http://www.pennstatehershey.org/web/irb/home/resources/investigator
18.0 Multi-Site Research
18.1
Communication Plans
N/A
18.2
Data Submission and Security Plan
N/A
18.3
Subject Enrollment
N/A
18.4
Reporting of Adverse Events and New Information
N/A]

Page 22 of 27 (V.04/27/2017)
18.5
Audit and Monitoring Plans
N/A
19.0 Adverse Event Reporting
19.1
Reporting Adverse Reactions and Unanticipated Problems to the Responsible IRB
In accordance with applicable policies of The Pennsylvania State University Institutional Review Board
(IRB), the investigator will report, to the IRB, any observed or reported harm (adverse event)
experienced by a subject or other individual, which in the opinion of the investigator is determined to be
(1) unexpected; and (2) probably related to the research procedures. Harms (adverse events) will be
submitted to the IRB in accordance with the IRB policies and procedures.
20.0 Study Monitoring, Auditing and Inspecting
20.1
Auditing and Inspecting
The investigator will permit study-related monitoring, audits, and inspections by the Penn State quality
assurance program office(s), IRB, the sponsor, and government regulatory bodies, of all study related
documents (e.g., source documents, regulatory documents, data collection instruments, study data
etc.).  The investigator will ensure the capability for inspections of applicable study-related facilities
(e.g., pharmacy, diagnostic laboratory, etc.).
21.0 Future Undetermined Research: Data and Specimen Banking
21.1
Data and/or specimens being stored
Plasma and whole blood samples will be stored with study identifier.  For participants who consent to
bio-banking, excess specimens not used in these studies will be placed in a biorepository for future
research with related health information. Bio-banking will be completed by the Penn State Institute for
Personalized Medicine (IPM) and will be linked to participant medical/demographic data through a
unique identification number assigned by the PRIDE IRB protocol.  Medical and demographic data
collected by the currently proposed study will be stored by the IPM per the PRIDE IRB protocol for future
use with bio-banked samples. Specimens within the IPM will be labeled with a second layer Study ID.  No
PHI will be stored with the samples.
21.2
Location of storage
IPM.  Banked specimens will be stored on the PS HMC campus in C2706 per the PRIDE IRB protocol.
21.3
Duration of storage
Per standard IPM operating procedure where specimens and data will be stored indefinitely.
21.4
Access to data and/or specimens
Per standard IPM operating procedure.  The honest broker associated with this study will have full
access to the master list and database through the PI.  These lists will include PHI and information from
the MR.  Specimen access will be limited to the PI and select members of the IPM staff.  
Access to banked specimens will be determined by the IPM staff per the PRIDE IRB protocol.
21.5
Procedures to release data or specimens
Per standard IPM operating procedure.  To request a release of banked specimens’ investigators will
submit, in writing, a copy of the PRIDE Sample Data Request Form. This request will be reviewed by the
PRIDE Access Committee per IRB protocol. Penn State investigators meeting PRIDE criteria will be given

Page 23 of 27 (V.04/27/2017)
access to the specimens, linked by medical record number to clinical data. Medical and demographic
data collected by the current study will not be provided.
Following the conclusion of this study, all remaining samples and associated data will become property
of the Institute for Personalized Medicine (IPM) and will be governed as described in the PRIDE protocol
40532.
21.6
Process for returning results
Per standard IPM operating procedure.  The procedure for returning all results of banked specimens will
be carried out in accordance with the IPM’s PRIDE IRB outlined in the document, PRIDE Return of
Research Results Request. The IPM’s PRIDE Program provides a forum for investigators to access and to
assume the responsibility of determining what should be done with the research results.  This relieves
researchers of the individual responsibility for determining what should be done with potentially
clinically significant results and ensures that any research results that could impact the clinical care of
the participant be appropriately transmitted. The PRIDE Program’s Research Results Board will meet
following notification by the PRIDE Access Committee that results have been returned and a voting
quorum will determine whether results merit a) no further action, b) informing participants with follow-
up CLIA genetic testing, c) informing participants with follow-up non-genetic studies, d) inform
participants without follow-up testing. If results are returned to participants they will be contacted by a
member of the PRIDE Research Results Board.
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