Food Insecurity is Associated with Mortality Among U.S. Adults with Nonalcoholic Fatty Liver Disease and Advanced Fibrosis

Food insecurity is a growing public health challenge in the U.S. and has been linked to nonalcoholic fatty liver disease (NAFLD) and advanced fibrosis. However, little is known of how food insecurity impacts mortality risk and healthcare utilization (HCU) in chronic liver disease.

Using a population-based cohort study of U.S. adults (≥20 years) in the National Health and Nutrition Examination Survey 1999-2014 with NAFLD (estimated by the U.S. Fatty Liver Index) and advanced fibrosis (estimated by the NAFLD fibrosis score, AST-to-platelet ratio index, or Fibrosis-4 Index), food security was measured using the Department of Agriculture Food Security Survey Module. The primary outcome was all-cause mortality from National Death Index data and the secondary outcome was HCU, defined as ≥2 inpatient and ≥4 outpatient visits, with Cox and logistic regression, respectively, estimating associations between food insecurity and outcomes.

Of 34,134 eligible participants (mean age 47 years, 51% women, 14% in poverty), 4,816 had NAFLD and 1,654 had advanced fibrosis with food insecurity present in 28% and 21%, respectively. All-cause age-adjusted mortality was 12 per 1000 person-years among NAFLD (food secure:11, food insecure:15) and 32 per 1000 person-years among advanced fibrosis participants (food secure:28, food insecure:50). In multivariable analyses, food insecurity was independently associated with higher mortality among participants with NAFLD (HR=1.46,95%CI:1.08-1.97) and advanced fibrosis (HR=1.37;95%CI:1.01-1.86) and greater outpatient HCU in NAFLD participants (OR=1.32;95%CI:1.05-1.67).

Food insecurity is significantly associated with greater all-cause mortality in adults with NAFLD and advanced fibrosis. Interventions that address food insecurity among adults with liver disease should be prioritized to improve health outcomes in this population.