The impact of food insecurity on chronic liver disease: A... : Hepatology Communications (original) (raw)

INTRODUCTION

Background

Chronic liver disease (CLD) is a substantial burden on health care systems, with annual costs in the United States surpassing $29.9 billion.1 Among the various etiologies of CLD, nonalcoholic fatty liver disease (NAFLD)—recently reclassified as metabolic dysfunction–associated steatotic liver disease (MASLD)2—is now the most common, driven by rising rates of obesity, insulin resistance, and other metabolic disorders. This shift highlights the critical role of a healthy diet in addressing metabolic risk factors and preventing progression of MASLD.3 Furthermore, the importance of dietary management extends beyond MASLD, as malnutrition is a well-recognized risk factor and poor prognostic indicator in patients with CLD.4–9 A healthy diet requires both affordability and consistent access to nutrient-rich foods that align with evidence-based dietary guidelines for CLD,3,9 which can be out of reach for many due to rising costs of food, among other factors. Understanding how food insecurity affects liver disease is critical for addressing the dual rising burdens of food insecurity and CLD in vulnerable populations.

Liver disease and diet

The liver is central to macronutrient metabolism, such that maintaining adequate liver function is essential to overall health. Metabolic disturbances in CLD include alterations in glucose metabolism, increased protein catabolism, and increased lipid oxidation, resulting in hepatic lipotoxicity and a deficiency in essential fatty acids.9 Protein-calorie malnutrition (PCM) is common in all stages of CLD and may be present in 65%–90% of patients with advanced disease.6 Severe PCM can undermine the capacity for liver regeneration and functional restoration and is associated with other complications such as esophageal varices, hepatic encephalopathy, and increased surgical morbidity and mortality.6,8 Consequently, diet is an important prognostic and therapeutic factor for patients with liver disease.

The unique pathophysiology of liver disease requires dietary patterns distinct from those recommended for other chronic conditions, creating additional barriers to food access. For instance, patients with cirrhosis are typically advised to follow high-protein, high-calorie diets with small, frequent meals to combat malnutrition and prevent muscle wasting.8 Sodium intake is often restricted in patients with ascites to reduce fluid retention. Moreover, deficiencies in fat-soluble vitamins (A, D, E, and K) and trace elements such as zinc and selenium are common, further complicating disease management.6,8,10 These dietary needs present additional barriers for food-insecure individuals, who frequently rely on inexpensive, nutrient-poor foods that exacerbate metabolic dysfunction.11 Despite this, there is very limited data on how food insecurity impacts the development and outcome of liver diseases. Recent op-eds and commentaries have underscored the need for more research into how socioeconomic factors, particularly food insecurity, contribute to liver disease.12–14

Food insecurity and socioeconomic status

Food insecurity, defined as limited or uncertain access to adequate food, is both a marker of poverty and a reflection of broader structural inequities.15 In 2023, more than 47 million Americans lived in food-insecure households, with disproportionately higher rates among non-Hispanic Black and Hispanic communities.16–18 The COVID-19 pandemic has exacerbated these disparities.19 In high-income nations, food insecurity is paradoxically linked to obesity, largely due to lower cost, energy-dense, high-fat, and ultra-processed foods.20 Food insecurity has a well-established relationship with an increased risk of chronic conditions such as diabetes, obesity, hypertension, and cardiovascular disease,20–22 but data on its impact on liver disease remains sparse.

Limited access to health care, chronic stress, lack of safe and accessible spaces for physical activity, lower education and health literacy, and lack of access to healthy foods all contribute to higher risks for developing cardiometabolic diseases.23 MASLD shares many of the same risk factors as cardiometabolic diseases, such as insulin resistance and dyslipidemia. Understanding how food insecurity impacts not only MASLD but also other forms of liver disease is crucial for improving disease outcomes, especially in underserved populations. Addressing food insecurity in these communities is not only vital for managing liver disease but also for reducing the burden of chronic conditions and improving overall health outcomes.

Purpose of review

Despite the clear link between diet, socioeconomic status (SES), and liver disease, the relationship between food insecurity and liver disease remains poorly understood. We have conducted the first systematic review to date to fill this gap by examining the available evidence on how food insecurity impacts the development, progression, and outcomes of liver diseases. By reviewing the current evidence on this critical issue, we hope to identify data gaps and inform future research opportunities and public health policies aimed at addressing food insecurity and improving health outcomes for vulnerable populations with liver disease. The full review question is as follows: What is the current evidence on the relationship between food insecurity and the prevalence, development, morbidity, and mortality associated with liver disease?

METHODS

Literature search

We searched Medline (PubMed), CINAHL, Embase, and the Web of Science databases with no temporal or language restrictions for relevant publications. The search terms and strategy were designed after consultation with a librarian and are reported in Supplemental Table S1, https://links.lww.com/HC9/C103. All publications were uploaded into Covidence, and 2 reviewers (Laila M. Elias and Jordy E. Agins) used this software to independently evaluate each record. The initial screening is based on the title and abstract of studies identified for inclusion. Then, the full texts of potentially eligible studies were examined to determine whether they met the inclusion criteria. The selection process is further described in the Prisma flowchart, as shown in Figure 1. Any conflicting decisions were adjudicated by the entire research team.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) studies that assessed the link between food insecurity and the presence or development of liver disease; (2) studies that evaluate the association between food insecurity and liver disease morbidity, and/or mortality; and (3) papers published in the English language, or with a qualified reader available. We excluded (1) animal studies, (2) editorials, (3) personal opinions, (4) abstracts/posters, and (5) review articles. Papers were also excluded if they focused on nutritional content/quality or famine/starvation rather than food insecurity. All papers included were conducted in accordance with both the Declaration of Helsinki and Istanbul.

Information extraction

After reading the full articles, the following information was extracted from the retained final studies: authors, year of publication, country where the study was carried out, study design, study population and characteristics, definition and measurement of food insecurity, definition and measurement of liver disease, and main findings. In addition, the full-text articles were examined to exclude duplicate entries by the same first or corresponding author, and they were also judged as to whether there were overlaps in content. Then, full-text versions of the included articles were evaluated by the authors to compile several tables to summarize the findings between food insecurity and liver disease.

Evaluation of the quality of selected studies and the assessment of the risk of bias

The evaluation of the quality of selected studies and the assessment of the risk of bias were carried out using the Mixed Methods Appraisal Tool (MMAT). The MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews, that is, reviews that include qualitative, quantitative, and mixed methods studies.

RESULTS

Overall

The search was performed in May 2024 and updated in April 2025. The search strategy is reported in Figure 1. A total of 17,609 studies were identified, and 4875 duplicates were excluded. During the screening phase, 12,734 studies were excluded based on the title and abstract, and 88 full-text papers were retrieved and read. Subsequently, 71 manuscripts were excluded: 11 for not focusing on liver disease outcomes, 21 for not focusing on food insecurity (rather nutritional content or starvation/famine), 37 for publication type (review, abstract, poster), and 2 for not being written in English with no translation. After review, 17 articles24–40 met the inclusion criteria. Out of the 17 identified studies, the oldest was published in 2020 and the newest in 2025. Fifteen (88%) studies were conducted in the United States, and 2 (12%) were conducted in Iran. There was 1 case–control study (6%), 10 cross-sectional studies (59%), 2 retrospective cohort studies (12%), 2 prospective cohort studies (12%), and 2 population-based cohort studies (12%). Thirteen (76%) studies looked at adult populations, and the remaining 4 (24%) looked at pediatric populations. The characteristics of each study are outlined in Table 1.

FIGURE 1:

Prisma flowchart.

TABLE 1 - Characteristics of each study

Abbreviations: NHANES, National Health and Nutrition Examination Survey; SES, socioeconomic status.

Liver disease focus and outcome

Out of the 17 studies, 15 (88%) focused on NAFLD, or MASLD, updated on the new classification, 5 (29%) on liver fibrosis, 1 (6%) on liver cirrhosis, 1 (6%) on HCC, and 1 (6%) on liver transplant. Of the outcomes, 13 (76%) studies focused on the prevalence or development of liver disease, 3 (18%) on mortality, and 1 (6%) on perioperative outcomes following HCC resection. Liver disease outcomes were assessed using a variety of methods. Ten studies (59%) relied on noninvasive techniques to measure liver stiffness and fibrosis. Transient elastography, specifically using vibration-controlled transient elastography (VCTE), was used to evaluate liver stiffness and fibrosis in 6 studies (35%). In addition, other noninvasive scoring systems, such as the NAFLD Fibrosis Score (NFS) and Fibrosis-4 (FIB-4) index, were employed to estimate the degree of fibrosis in patients. One study used MRI proton density fat fraction (MRI-PDFF) to assess hepatic steatosis, and another study employed ultrasound-based elastography to evaluate liver disease. One study used biochemical markers such as ALT and AST to assess for liver injury in relation to food insecurity. In addition, 4 studies (24%) evaluated liver-related mortality and transplant metrics using national registries.

Food insecurity measurement

Food insecurity was most frequently measured with the USDA Household Food Security Survey Module (10, 59%). This is an 18-item survey that is used to assess different levels of household food security and is typically considered the gold standard in measuring food insecurity.41 Other food insecurity measures included the Six-Item Short Form Household Food Security Survey (2, 12%) and the Food Insecurity Experience Scale (1, 6%) which are both adapted from the USDA household Food Security Survey, data from the Food Environment Atlas (2, 12%), data from the Feeding America: Mapping the Meal Gap reports (1, 6%), and the Hunger Vital Sign (1, 6%), which is a validated 2-item food insecurity screening tool.42

Key findings

The review revealed an association between food insecurity and development, prevalence, and poor liver disease outcomes. According to the findings by Maxwell et al,35 experiencing household food insecurity at 4 years of age was associated with an almost fourfold increased odds of MASLD in later childhood. In addition, Paik et al28 found that adolescents 12–18 years old from low-income households with food insecurity had a 3-fold increased risk of MASLD. Among adults, in a case–control study by Tutunchi et el,37 food insecurity was significantly more prevalent among patients with MASLD compared with control groups, with rates of 56.8% and 26.1% respectively (p <0.001). Studies demonstrated that food insecurity was associated with a higher prevalence of liver disease, with one reporting an increased OR of 1.38 and 2.20 for the presence of MASLD and advanced liver fibrosis, respectively.26,29,40 Food-insecure individuals consistently exhibited higher rates of hepatic steatosis, liver fibrosis, and elevated liver stiffness, suggesting a strong link between poor food access and liver disease progression.33,34,36 In the study by Kim et al,26 food-insecure patients had a 40% higher risk of developing advanced fibrosis compared with food-secure individuals (OR: 1.40, 95% CI: 1.04–1.88). Kardashian et al30 found food insecurity to be associated with a higher risk of all-cause mortality in both MASLD (HR 1.46, 95% CI: 1.08–1.97) and advanced fibrosis (HR: 1.37, 95% CI: 1.01–1.86) after adjustment for demographic, socioeconomic, and metabolic risk factors. In this same study, food insecurity was also associated with increased outpatient health care utilization among MASLD patients (OR: 1.31, 95% CI: 1.05–1.63).30 The study by Paik et al38 highlighted that counties with the highest MASLD-related mortality had higher rates of food desert (8.7% vs. 5.8%, p<0.001) compared with those with the lowest mortality. In fact, it was found that MASLD mortality was twice as high in counties with the greatest food desert burden compared with those with the least (25.65 vs. 12.75 per 100,000; 95% CI: 2.66–4.72). Furthermore, Younossi et al’s multi-country study found that in high Socio-Demographic Index (SDI) countries, MASLD prevalence was significantly higher in those in the top tertile of food insecurity compared with the bottom tertile (mean, 26.73% vs. 18.87%, _p_=0.0001). In contrast, in low SDI countries, the opposite was true (19.45% vs. 24.96%, _p_=0.0008).39 Of the included studies, only one discusses the effect of participating in the Supplemental Nutrition Assistance Program (SNAP). In this study by Paik et al,38 it was found that counties with a higher percentage of SNAP participation among the eligible population were associated with lower MASLD-related mortality rates (p<0.001). These studies highlight the importance of food insecurity as a potentially modifiable risk factor in developing and managing liver disease and preventing further progression. The results from each study are summarized in Table 2.

TABLE 2 - Tools and results of each study

Abbreviations: LT, liver transplantation; SLD, steatotic liver disease.

The Mixed Methods Appraisal Tool was used to evaluate the quality of each selected study and the assessment of the risk of bias. These results are reported in the Supplemental Materials as Tables S2–S4, https://links.lww.com/HC9/C103, based on whether the paper utilized a cohort, cross-sectional, or case–control study design, respectively. Most studies (15/17, 88%) met 5/5 criteria, thus were high quality and low risk of bias. The remaining 2 studies (12%) met 4/5 criteria, due to not accounting for confounders in the study design.

DISCUSSION

This systematic review highlights the previously unexplored relationship between food insecurity and liver disease, an issue that has garnered increased attention in the wake of the COVID-19 pandemic. Notably, all studies included in this review were published within the last 5 years, reflecting a growing recognition of food insecurity as a structural determinant of health relevant to liver disease. The economic strain and social disruptions caused by the pandemic brought food insecurity to the forefront of public health discussions, particularly in the context of chronic disease.43

The findings of this review emphasize the need for a stronger focus on food insecurity in future hepatology research. There are significant gaps in the literature, particularly concerning diseases other than MASLD, such as alcohol-associated liver disease, autoimmune liver disease, or viral hepatitis. It is also important to note that some studies in this review were conducted before the adoption of the new MASLD nomenclature and used older definitions such as NAFLD. This variation in disease definitions may contribute to heterogeneity in the findings and limit the ability to fully compare outcomes across studies. Future research should apply updated MASLD criteria to improve consistency and relevance in hepatology research.

There is also limited data regarding the role of food insecurity in the complications patients with liver disease face, including progression of disease and health care utilization. Evidence suggests that experiences of food insecurity increase overall health care costs and utilization.44 The additive contributions of already higher rates of hospitalization in liver disease45,46 with increases related to experiences of food insecurity, deserve further evaluation. The unique dietary needs of liver disease patients, which may differ substantially from other metabolic disorders, necessitate a tailored approach to addressing food insecurity. Among patients with liver diseases, specific subgroups may additionally have distinct dietary recommendations (eg, compensated vs. decompensated cirrhosis, MASLD vs. alcohol-associated liver disease), adding further complexity to disease management. While food insecurity is a well-established contributor to poor health, most studies in this review did not directly assess diet quality as an independent variable in relation to liver disease outcomes. Poor or inadequate nutrition in liver disease patients not only worsens outcomes but can also accelerate the progression of liver fibrosis and worsen cirrhosis complications.6,9 Understanding how food insecurity interacts with these dietary requirements in the setting of underlying food insecurity will be essential in developing more effective, patient-specific interventions. Understanding how food insecurity can directly and indirectly contribute to poor diet quality will be important in future research.

Moreover, very few studies have explored the link between food insecurity and malnutrition, frailty, or sarcopenia risk, despite the fact that patients with liver disease are at an increased baseline risk of these conditions.5 Decompensated patients are particularly vulnerable, facing the highest morbidity and mortality risks and the most complex dietary needs.9,47,48 Understanding where food insecurity fits into this pathway is essential for ensuring optimal outcomes.

Pre-liver and post-liver transplant patients also warrant consideration. Food insecurity may significantly impact nutritional optimization before transplant, which is critical for surgical outcomes, and post-transplant, where patients must adhere to strict dietary regimens to prevent complications and support recovery.7 These populations remain underrepresented in the current literature and deserve further attention.

Despite the associations identified in this review, significant gaps remain in the research, particularly regarding intervention studies and clinical trials. To date, no studies have employed causal approaches to understand the directionality of the relationship between food insecurity and liver disease. This lack of causal evidence limits our ability to determine whether food insecurity exacerbates liver disease progression or whether advanced liver disease increases the likelihood of food insecurity due to socioeconomic factors. There is also a lack of implementation studies on systematically identifying food insecurity in hepatology clinics. Incorporating this screening into clinical workflows would not only provide valuable data to deepen our understanding of this relationship but also create opportunities to design and test tailored interventions. By addressing food insecurity proactively in hepatology clinics, researchers and clinicians can better identify at-risk populations and evaluate which interventions are most effective in improving both nutritional status and liver health outcomes.

While evidence-based practices are urgently needed, efforts should be made to address food insecurity and the surrounding food environment in adults and children, given its demonstrated link to liver disease. Eligible patients should be referred to evidence-based food resources, including benefit programs like the Supplemental Nutrition Assistance Program (SNAP),49 as well as local food pantries and soup kitchens. Screening for food insecurity within hepatology clinics and implementing patient-specific interventions could transform care and improve long-term outcomes. While one study we looked at found that counties with higher SNAP (also known as food stamps) enrollment had lower MASLD-related mortality, there is limited evaluation of SNAP as a program and its impact on liver disease. Future research should evaluate interventions aimed at addressing food insecurity in liver disease populations, like SNAP, and assess whether these interventions can slow disease progression or reduce health care utilization.

Limitations

This review faces several limitations, specifically regarding the scope of the studies analyzed. A large proportion (6, 42.8%) of the included studies utilized data from the National Health and Nutrition Examination Survey (NHANES), thus several studies may be using overlapping data and repeat a single finding among a static population rather than capture different aspects of food insecurity and liver disease faced by varying populations. Another consideration of the repeated use of NHANES data is that it only provides cross-sectional information. This design lacks temporal information, meaning it cannot clarify whether the exposure (food insecurity) occurred before the outcome (liver disease) or vice versa. It should be considered that food insecurity in these studies is identified by self-reported questionnaires, and could be subject to recall bias, social desirability bias, and potential misunderstanding of questions.

CONCLUSIONS

While current research demonstrates a recent uptick in interest in the relationship between food insecurity and liver disease, there remain significant gaps in the evidence. Opportunities exist for causal methodology to understand the direction of the relationship between food insecurity and liver disease. Better data collection at the individual level will inform the prevalence of food insecurity across liver disease etiologies and allow for the development of interventions to improve food insecurity rates. Given the increased attention to structural determinants of health since the COVID-19 pandemic, care for patients with liver disease must continue apace to include food insecurity as a likely modifiable risk factor in the care of patients.

FUNDING INFORMATION

Financial Support and Sponsorship: 1R01NR021522.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.

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Keywords:

diet and nutrition; food security; health disparities; liver fibrosis; metabolic dysfunction–associated steatotic liver disease

Supplemental Digital Content

Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.