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Limited or a lack of access to nutritious food led to poorer clinical outcomes in adults with advanced liver fibrosis and non-alcoholic fatty liver disease (NAFLD), a retrospective study found.

Food insecurity was independently associated with greater mortality rates in adults with advanced fibrosis (HR 1.37, 95% CI 1.01-1.86, P=0.040) and NAFLD (HR 1.46, 95% CI 1.08-1.97, P=0.010), reported Ani Kardashian, MD, of the University of Southern California in Los Angeles.

Food insecurity was also associated with higher mortality rates in adults with advanced fibrosis who live in poverty (HR 2.27, 95% CI 1.41-3.66, P= 0.015), Kardashian said at the European Association for the Study of the Liver (EASL) annual conference.

have identified food insecurity as a risk for NAFLD, with a higher odds of developing NAFLD among food insecure people and people with obesity compared to those who had adequate access to food and with a normal body weight.

Kardashian said at the EASL press conference that about 35 million people and 18 million households in the U.S. experienced some degree of food insecurity before the pandemic, and that number is now estimated to be as high as 50 million people.

She added that in recent years, food insecurity emerged as an important social determinant, associated with a higher risk of NAFLD and NAFLD-associated liver fibrosis.

Lesser known is the impact of food insecurity on long-term health outcomes. "That's what we really wanted to study in our analysis," Kardashian said.

Her group used data from the (NHANES) from 1999 to 2014. There were 34,134 adults age 20 and older, who were studied over a median of 7.2 years. The main outcome was all-cause mortality.

Overall, 4,816 adults had NAFLD and 1,654 had advanced fibrosis. Those with advanced fibrosis were older (average age 69 vs 51, respectively), but 55-58% of both groups were men, and 14-15% lived below the poverty line. Among those with food insecurity, 28% had NAFLD and 21% had advanced fibrosis.

Kardashian said people with food insecurity in both groups were more likely to suffer from poverty, have less than a high school education, be publicly insured or have no insurance, and be non-Hispanic white.

Her group found that among those who were food insecure, average BMI was 34-35, while 46% of those with advanced fibrosis and 23% of those with NAFLD had diabetes.

Not surprisingly, mortality rates were higher for those who were food insecure. For adults with NAFLD, mortality rates were 11 per 1,000 person-years among those who were food secure and 15 per 1,000 person-years for those who were food insecure. Among adults with advanced fibrosis, mortality rates were 28 per 1,000 person-years for food secure individuals versus 50 per 1,000 person-years among those who were food insecure.

In multivariable regression analyses, food insecurity was associated with a 46% higher risk of death in people with NAFLD -- after controlling for sociodemographic factors, poverty, insurance status, education level, and metabolic comorbidities -- and a 37% higher risk for death in adults with advanced fibrosis, Kardashian said.

Social factors, including food insecurity, are often barriers to healthy eating and can be associated with comorbidities (hypertension and more), Yamini Natarajan, MD, of Baylor College of Medicine in Houston, told 番茄社区app.

Food insecurity often leads to obesity, as individuals have less access to nutritious, quality food, and instead eat higher calorie food, said Natarajan, who was not involved with the research.

This makes "it harder to lose weight, as they don't know when their next meal is coming," said Natarajan, "so they have increased fat content and diabetes."

Key factors in preventing NAFLD include a healthy diet, maintaining a healthy weight, and exercise, she noted.

"We need to give patients systemic help," Natarajan added, saying that more social programs are needed beyond the Supplemental Nutrition Assistance Program (SNAP), or food stamps. "Just within the clinic, we can only control so much," explaining this is especially important during the pandemic. As a society, we need to work on more food access, she said.

"This study highlights the importance of us really focusing on upstream social determinant of health in the long-term outcomes of people with NAFLD and advanced liver fibrosis," Kardashian said, and recommended connecting patients to food assistance programs, partnering with food banks, and developing collaborative programs to improve diet.

She added that the next steps in the research would be to include more robust markers for liver fibrosis, using FibroScan data as opposed to biomarkers, and non-invasive risk calculators. Limitations of the study included the use of survey data and not having larger numbers for each disease group.

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