Abstract

Background: Food insecurity can increase the risk for NAFLD. We assessed the association between food insecurity and NAFLD among adolescents in the United States.

Methods: Data for adolescents (aged 12-18) from the National Health and Nutrition Examination Survey (2017-2018) were analyzed. Food insecurity was assessed using the U.S. Department of Agriculture (USDA) Child Food Security Survey Module, including 8 food security questions. Adolescents with 2 or more affirmative responses are classified as having food Insecurity according to USDA guidelines. Participation in Supplemental Nutrition Assistance Program (SNAP) was defined as anyone in household participating in the past 12 months. Low household (HH) income level was defined as household income <138% federal poverty level [FPL]). NAFLD was defined by transient elastography (TE) with a controlled attenuation parameter (CAP) of ≥ 285 dB/m without other causes of liver disease. Significant fibrosis (SF) and advanced fibrosis (AF) was defined by TE liver stiffness >8.0 kPa and 13.1 kPa, respectively.

Results: Among 771 adolescents included in NHANES 2017-2018 [mean age 14.7 years; 52.5% male; 50.9% white, 12.7% Black, and 16.7% Mexican American, 7.7% Hispanic and 4.5% Asian], 9.8% reported food insecurity and 10.8% had NAFLD; 22.5% obesity; 45.4% central obesity; 1.0% diabetes; 20.9% Pre-diabetes; 4.5% hypertension, 41.6% hyperlipidemia, 17.3% high C-reactive; 2.5% SF; and 0.5% AF. Of the adolescents who were considered food insecure, 98.9% relied on low-cost food, 93.2% couldn’t get balanced meal and 51.5% did not eat enough food. Compared to the food-secure adolescents, food-insecure adolescents had higher rates of NAFLD (18.7% vs. 9.9%) and higher rates of advanced hepatic fibrosis (2.8% vs. 0.3%). Furthermore, they were more likely to be non-US citizens (88.8% vs. 95.6%), live with lower HH income (70.4% vs. 25.7%) and lower head of HH education (29.2% vs. 17.0%) and higher rates of SNAP participation (62.4% vs. 25.1%). There were no differences in metabolic diseases (T2D etc.) according to food insecurity. A model adjusted for demographic, metabolic diseases and SNAP participation showed that food insecurity (Odds ratio [OR]=2.62, 95% confidence interval [1.07-6.41]), obesity (OR=15.56 [7.71-31.50]), and hypertension (OR=4.93 [2.67-9.14]) were independently associated with NAFLD. An additional multivariable model showed that living in a food-insecure adolescents living in lower HH income was associated with an even higher risk of NAFLD (OR=4.79 [1.44-15.86]) versus adolescents living in higher HH income.

Conclusion: Food insufficiency and low household income drive NAFLD risk for adolescents.