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Oliveira et al. Hepatoma Res 2020;6:xx I http://dx.doi.org/10.20517/2394-5079.2020.73 Page 7 of 13

A B

C D

Figure 3. The histological spectrum of nonalcoholic fatty liver disease in lean vs.overweight vs.obese across regions. A: steatosis grade; B:
lobular inflammation grade; C: hepatocellular ballooning; D: fibrosis stage

compared to subjects from the US (mean grade 1.9), France (mean grade 1.8), and India (mean grade 2.2).
Lean subjects from Brazil also had greater lobular inflammation (mean grade 1.5) compared to subjects
from the other countries (mean grade range 0.5-0.7) (P < 0.0001). The ballooning grade was similar across
the US, Brazilian, and Indian cohorts but was lower in lean subjects from the French cohort (P < 0.0001).
Similarly, the mean fibrosis stage was similar across the US, Brazil, and India but higher than that seen in
the French group (P < 0.0013).

Overweight subjects
The prevalence of hypertension and T2DM was higher in the subjects from Brazil. The mean HOMA
scores were similar across the four groups. As noted in the lean subjects, a proportion of subjects were
still relatively insulin sensitive whereas a proportion was insulin resistant with beta cell failure. Subjects
from Brazil had more advanced IR with a majority of subjects with a fasting plasma glucose > 100 mg/dL.
Interestingly, the ballooning grade was more severe in overweight subjects from India compared to those
from the USA and France (1.7 vs. 1 vs. 0.8, P < 0.0001). Subjects from Brazil had intermediate degrees of
ballooning injury (mean grade 1.2). The fibrosis stage in overweight subjects in the Indian cohort was
modestly higher than the other cohorts (mean: 1.8 vs. 0.6 vs. 1 vs. 1.2 India vs. US vs. France vs. Brazil) [Table 3].

Obese subjects
In Brazil almost 80% of the obese subjects were hypertensive while 49.5%, 44.4%, and 18.2% of obese