Food insecurity is associated with magnetic resonance-determined nonalcoholic fatty liver and liver fibrosis in low-income, middle-aged adults with and without HIV

Abstract

Background: Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in the United States. Food-insecure individuals often depend on low-cost, energy-dense but nutritionally poor foods, resulting in obesity and chronic diseases related to NAFLD.

Objectives: To determine whether food insecurity is associated with NAFLD in a cohort of HIV and hepatitis C virus (HCV) infected and uninfected adults.

Methods: We conducted a cross-sectional analysis of low-income, middle-aged adults from the Miami Adult Studies on HIV (MASH) cohort without a history of excessive alcohol consumption. Food security was assessed with the USDA's Household Food Security Survey. MRIs were used to assess liver steatosis and fibrosis. Metabolic parameters were assessed from fasting blood, anthropometrics, and vitals.

Results: Of the total 603 participants, 32.0% reported food insecurity. The prevalences of NAFLD, fibrosis, and advanced fibrosis were 16.1%, 15.1%, and 4.6%, respectively. For every 5 kg/m2 increase in BMI, the odds of NAFLD increased by a factor of 3.83 (95% CI, 2.37-6.19) in food-insecure participants compared to 1.32 (95% CI, 1.04-1.67) in food-secure participants. Food insecurity was associated with increased odds for any liver fibrosis (OR, 1.65; 95% CI, 1.01-2.72) and advanced liver fibrosis (OR, 2.82; 95% CI, 1.22-6.54), adjusted for confounders. HIV and HCV infections were associated with increased risks for fibrosis, but the relationship between food insecurity and liver fibrosis did not differ between infected and uninfected participants.

Conclusions: Among low-income, middle-aged adults, food insecurity exacerbated the risk for NAFLD associated with a higher BMI and independently increased the risk for advanced liver fibrosis. People who experience food insecurity, particularly those vulnerable to chronic diseases and viral infections, may be at increased risk for liver-related morbidity and mortality. Improving access to adequate nutrition and preventing obesity among low-income groups may lessen the growing burden of NAFLD and other chronic diseases.

Keywords: HIV; MR elastography; NAFLD; food insecurity; liver fibrosis; magnetic resonance imaging; substance abuse; vulnerable populations.

FIGURE 2

Predicted probability plot for NAFLD by BMI in food-secure versus food-insecure participants (n = 603). A multivariable logistic regression model was used to examine the relationship between food insecurity and NAFLD, adjusting for age, sex, race/ethnicity, household size, hyperglycemia, hypertriglyceridemia, and included BMI, as well as an interaction term for food insecurity and BMI (see Table 3). There was a significant interaction effect between FI and BMI (P < 0.0001). In other words, the effect of FI on NAFLD was dependent on BMI, and vice versa. Estimates for the effects of food insecurity on NAFLD were obtained for BMIs of 25, 30, and 35 kg/m², which correspond to the cutoffs for overweight, obesity Class I, and obesity Class II, respectively. For every 5-unit increase in BMI, the odds of NAFLD were 3.83 (95% CI, 2.37–6.19; P < 0.0001) times higher in food-insecure participants (solid line) compared to 1.32 (95% CI, 1.04–1.67; P = 0.02) times higher in food-secure participants (dotted line). Likewise, compared to food-secure participants, the odds for NAFLD in food-insecure participants were: 0.20 (95% CI, 0.07–0.57) at 25.0 kg/m²; 0.59 (95% CI, 0.31–1.14) at 30.0 kg/m²; and 1.91 (95% CI, 1.02–3.59) at 35.0 kg/m². Abbreviations: FI, food insecurity; NAFLD, nonalcoholic fatty liver disease.

FIGURE 1

Comparison of liver parameters by food security status. Of the 603 MASH cohort participants, 97 (16.1%) had nonalcoholic fatty liver, 91 (15.1%) had liver fibrosis, and 28 (4.6%) had advanced fibrosis. Liver fat content was assessed via MRI-PDFF. Liver fibrosis was assessed via LS measurement by MRE. These were conducted on a 3T Siemens MAGNETOM Prisma scanner. Nonalcoholic fatty liver was considered present if the MRI-PDFF was >5%. Liver fibrosis was defined as LS ≥ 2.9 kPa, which is consistent with liver fibrosis Stage 1 or higher, and advanced fibrosis was defined as LS ≥ 3.8 kPa, which is consistent with liver fibrosis Stage 3 or higher. Chi-square tests were performed to test for differences between food-secure and food-insecure participants. *P < 0.05; ^P < 0.1. Abbreviations: LS, liver stiffness; MRE, magnetic resonance elastography; NAFLD, nonalcoholic fatty liver disease; PDFF, proton density fat fraction.