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Mantovani et al. Hepatoma Res 2020;6:78 I http://dx.doi.org/10.20517/2394-5079.2020.75 Page 3 of 22

Figure 1. Main hepatic and extrahepatic complications associated with Nonalcoholic fatty liver disease in patients with type 2 diabetes
mellitus

steatosis on ultrasound in patients with T2DM are also available [77,78] . For instance, in a cross-sectional
[77]
study of 874 diabetic and non-diabetic patients, Wang et al. documented that the prevalence of T2DM
among patients with mild liver steatosis (on ultrasound) was 7.5%, whereas the percentage of T2DM
individuals among those with moderate-to-severe liver steatosis was 23.4% (P < 0.05).

These results clearly show that among the observational studies using liver ultrasound for the diagnosis
of NALFD, the prevalence of NAFLD varies across different countries and clinical settings and it is
influenced by different prevalence of obesity and degree of insulin resistance, as well as by the fact that
ultrasound is an operator-dependent imaging technique. Indeed, the observational studies involving
European or USA patients have reported a prevalence of NAFLD higher than that observed in the studies
involving Asian patients. Additional factors that might explain these findings are different lifestyles (i.e.,
sedentary, physical inactivity), diets (i.e., high caloric diets, especially in the form of carbohydrates and