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The Liver Meeting
November Fri, Nov 10, 2023 - Mon, Nov 14, 2023

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Food Insecurity, Low Income Drive MASLD in US Adolescents
  AASLD 2023, The Liver Meeting, November 10-14, 2023, Boston
Mark Mascolini
Food insecurity and low household income independently boosted odds of metabolic dysfunction-associated steatotic liver disease (MASLD) in a study of 711 US adolescents [1]. Researchers who conducted the study proposed the link between food insecurity and MASLD "is most likely the result of not being able to eat a balanced meal and more likely having to purchase low-cost food."
James Paik of the Global NASH Council and collaborators from other institutions noted that the worldwide prevalence of MASLD (or NAFLD) leapt to 38% among young adults in the past decade. Food insecurity, already linked to obesity in adults, the investigators proposed, may also hike MASLD risk in children and adolescents, but little work has addressed this possibility. Ten percent of US households have child food insecurity, according to these researchers. To address these issues, Paik and colleagues examined potential links between socioeconomic factors and MASLD in adolescents (12 to 18 years old) who participated in the National Health and Nutrition Examination Survey (NHANES) in 2017-2018.
The researchers designated a child food insecure if they affirmatively answered at least 2 of the 8 questions on the US Department of Agriculture Child Food Security Survey Module. Low household income meant a poverty income ratio below 138% of the federal poverty level. Low head of household education meant having less than a high school education. The research team defined MASLD by transient elastography with a combined attenuation parameter (CAP) of 285 dB/m or greater without other causes of liver disease. Significant fibrosis meant a transient elastography liver stiffness greater than 8.0 kPa, and advanced fibrosis meant liver stiffness at 13.1 kPa.
Of the 711 adolescents studied, 73 (10.3%) had MASLD. A significantly higher proportion of the MASLD group had food insecurity (17.05% vs 8.94%, P = 0.0275). Compared with the non-MASLD contingent, adolescents with MASLD had higher proportions with low household income (47.19% vs 28.20%, P = 0.0008), low head of household education (34.94% vs 16.29%, P = 0.0011), and using the Supplemental Nutrition Assistance Program (SNAP) (38.87% vs 27.53%, P = 0.0716). Adolescents with MASLD differed significantly from those without the disease in two child food security categories: relied on low-cost food for child (20.37% vs 12.10%, P = 0.0371) and couldn't feed child a balanced meal (20.01% vs 9.56%, P = 0.0112).
Significantly higher proportions of the MASLD group than the non-MASLD group had metabolic disorders including obesity (81.69% vs 15.37%, P < 0.0001), central obesity (95.09% vs 39.39%, P < 0.001), prediabetes (27.38% vs 20.10%, P = 0.0591), hypertension (19.62% vs 2.67%, P < 0.0001), hyperlipidemia (56.42% vs 39.84%, P = 0.0011), insulin resistance (87.45% vs 43.56%, P < 0.001), and high levels of high-sensitivity C-reactive protein, an inflammation marker (42.79% vs 14.33%, P < 0.001). The groups did not differ significantly in energy intake or healthy eating index score.
Compared with food-secure adolescents, those with food insecurity had significantly higher proportions with MASLD (18.72% vs 9.91%, P = 0.0275) and advanced fibrosis (2.80% vs 0.29%, P < 0.001). MASLD also proved more prevalent in adolescents living in a low-income household (16.01% vs 7.73%, P = 0.0008), those with lower head of household education level (20.33% vs 8.46%, P = 0.0011), and those using SNAP (14.56% vs 9.24%, P = 0.0716). Highest MASLD prevalence occurred in food-insecure adolescents who were Hispanic (31.1%) 15 to 18 years old (24.85%), black (20.94%), and girls (20.53%).
A multivariable model adjusted for age, sex, and race identified two factors independently associated with MASLD: food insecurity (odds ratio [OR] 2.37, 95% CI 1.24 to 4.53, P = 0.0127) and low household income (OR 2.07, 95% CI 1.26 to 3.40, P = 0.0071). When this model further adjusted for parents' marital status, obesity, and hypertension, only food insecurity remained an independent predictor of MASLD (OR 2.43, 95% CI 1.20 to 4.92, P = 0.0168). Compared with high-income households, low-income households with food insecurity had more than 3-fold higher odds of MASLD (OR 3.16, 95% CI 1.12 to 8.91, P = 0.0318). The researchers concluded that food insecurity and low household income are "a major driver" of high MASLD prevalence in US adolescents. They added that programs addressing food insecurity in adolescents, like SNAP, may improve adolescents' diet.
1. Paik JM, Duong S, Zelber-Sagi S, et al. Food insecurity and household income substantially increase the risk of NAFLD among adolescent children in the United States. AASLD 2023, The Liver Meeting, November 10-14, 2023, Boston.