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These patients may display subtle metabolic abnormalities insulin resistance, dyslipidemia, or visceral adiposity despite appearing lean. Clinical markers such as waist circumference, hepatic imaging findings, and elevated liver enzymes (ALT/AST) should prompt further evaluation even when BMI is below 25 kg/m

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A summary score is generated by multiplying individual scores for severity (range 19) and frequency (range 18) for each item and adding these up