Poverty Harms Patients With Diabetes, Fatty Liver

Neil Osterweil

April 17, 2018

PARIS — For patients with diabetes and nonalcoholic fatty liver disease (NAFLD), the risk for advanced hepatic fibrosis increases nearly three times when patients cannot consistently afford a healthy diet, results from a cross-sectional survey suggest.

In fact, food insecurity — limited or uncertain availability of nutritionally adequate foods — is a better predictor of advanced fibrosis than other socioeconomic variables, said investigator Russell Rosenblatt, MD, from the New York Presbyterian Hospital in New York City.

"We recommend that hepatologists now think of screening these patients for food insecurity," he said here at the International Liver Congress 2018.

In the United States, food insecurity began to rise around 2008, coinciding with the Great Recession. It is estimated that nearly 50 million Americans are at risk of going hungry at least some of the time. In Europe, a similar trend began to emerge in 2010, with the advent of austerity measures, Rosenblatt reported.

The link between food insecurity and diabetes, a major risk factor NAFLD, stems from the fact that calorie-dense but nutritionally poor foods tend to be considerably cheaper than healthy foods. People with food insecurity tend to have poor nutrition and higher levels of obesity, metabolic syndrome, and diabetes.

The American Diabetes Association has made screening for food insecurity when patients with diabetes are evaluated a class A recommendation.

To explore the strength of the association between food security and advanced fibrosis in patients with diabetes and NAFLD, Rosenblatt and his colleagues analyzed data on adults with diabetes from the 2005 to 2014 cycle of the National Health and Nutrition Examination Survey.

National Health and Nutrition Examination Survey

The team used a validated algorithm to identify patients with NAFLD and exclude people with viral hepatitis, women who consume more than two alcoholic drinks per day and men who consume more than three, people with liver transaminase levels above 500 IU/L, and pregnant women.

Study participants completed a 10-question validated food insecurity survey that assessed whether, in the previous year, they had worried about running out of food, worried about not having enough food until the next paycheck, skipped meals because they could not afford them, or lost weight because they did not have enough to eat.

Respondents were considered to have very low food security when they answered at least six questions in the affirmative, and full food security when they answered no questions in the affirmative.

The NHANES data indicate that the proportion of people with very low food security grew from 2005 to 2014. In the final study cohort, 1,289,057 people were deemed to have very low food security and 16,344,991 to have full food security.

People with very low food security were significantly younger than those with full food security, and significantly more likely to be female, to have a higher mean BMI, to have a higher level of hemoglobin A1c, to be insulin-dependent, and to have metabolic syndrome.

On univariate analysis, there was a trend toward advanced fibrosis in those with very low food security, but it was not significant. But on multivariate analysis, there were significant associations between certain risk factors and advanced fibrosis.

Table. Significant Risk Factors for Advanced Fibrosis on Multivariate Analysis

Risk Factor Adjusted Odds Ratio P Value
Very low food security 2.90 .03
Female 2.70 .002
Race: black vs white 0.29 .002
Race: Hispanic vs white 0.24 <.0001
BMI > 40 kg/m² 6.66 .008
Diabetes duration 0.95 .005
Hemoglobin A1c > 9% 3.25 .01


The lack of histologic data supporting a diagnosis of NAFLD was a limitation of the study, Rosenblatt acknowledged. However, patients with liver disease from other causes were excluded from the analysis and the prevalence of NAFLD in people with diabetes is higher than 75%, he pointed out.

Food insecurity might be exacerbated by poor health habits, such as the consumption of sugary beverages and lack of exercise, said briefing moderator Markus Cornberg, MD, PhD, from Hannover Medical School in Germany.

When evaluating patients for fibrosis, "I think we look more to overweight and overeating, but part the problem, in fact, is that they may not have the money to buy the good stuff," he told Medscape Medical News.

Rosenblatt and Cornberg have disclosed no relevant financial relationships.

International Liver Congress (ILC) 2018: Abstract PS-060. Presented April 12, 2018.

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