PNPLA3 and metabolic dysfunction-associated steatohepatitis: Several hypotheses can be considered for the greater severity of fibrosis in American countries, including lean NASH: (1) Higher caloric intake in the Americas, diet rich in fructose and trans lipids[31] low consumption of Mediterranean diet, including fiber and omega 3; (2) greater sedentary lifestyle in American countries; (3) presence of genetic factors such as PNPLA3[32]; and (4) dysbiosis, even in Lean NASH patients[33].