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  • Review Article
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Food inequity and insecurity and MASLD: burden, challenges, and interventions

Nature Reviews Gastroenterology & Hepatology (2024)Cite this article

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Abstract

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an ‘upstream’ risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Key points

  • Socially deprived communities bear the brunt of the increasing prevalence of liver disease, especially metabolic dysfunction-associated steatotic liver disease (MASLD), which is affected by social nutrition factors.

  • Socioeconomic disparities in liver disease are partially explained by disparities in major hepatic risk factors (for example, unhealthy diet, tobacco use, alcohol consumption and physical inactivity).

  • The unequal challenges in maintaining a healthy diet are related to social and commercial determinants of health, including food insecurity, all of which can be reduced through a systems approach.

  • Liver specialists must address food insecurity and limited availability of accessible and affordable nutritious food, which, coupled with low food literacy and aggressive marketing, lead to over-consumption of low-quality food.

  • To respond to the MASLD burden, the liver community needs to address food insecurity in the community and clinical care settings with ‘food is medicine’ and a social prescribing approach.

  • Bringing together multiple disciplines, including hepatology, social sciences, mental health and nutrition, with the support of the health system and policy, is needed to address health disparities such as food insecurity.

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Fig. 1: Trends in the number of people (millions) affected by food insecurity (2015–2021) and the worldwide prevalence of moderate or severe food insecurity (2021).
Fig. 2: Percentage change in a healthy diet cost (2018–2021) and number of people who cannot afford a healthy diet (2021).
Fig. 3: The relationship between food insecurity and liver disease progression: influence of structural and individual cofactors.
Fig. 4: Multidisciplinary, interdisciplinarity and convergence structures in MASLD management.

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Data availability

The structural databases utilized for the descriptive analysis, including visualizations (Figs. 1 and 2), are publicly accessible. These datasets can be downloaded from FAOSTAT (https://www.fao.org/faostat/en/data/FS) and from the report “The State of Food Security and Nutrition in the World 2023” (https://openknowledge.fao.org/handle/20.500.14283/cc3017en).

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Acknowledgements

The authors thank J. M. Paik for performing descriptive analysis with visualizations (Figs. 1 and 2). Institution: Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, Virginia, The Global NASH Council, Washington, DC. This work received no funding. D.I.W. and J.V.L. acknowledge support to ISGlobal from the grant CEX2018-000806-S funded by MCIN/AEI/10.13039/501100011033 and the ´Generalitat de Catalunya´ through the CERCA Programme, outside the submitted work.

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Authors and Affiliations

  1. School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

    Shira Zelber-Sagi

  2. The Global NASH Council, Washington, DC, USA

    Shira Zelber-Sagi, Zobair M. Younossi & Jeffrey V. Lazarus

  3. Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, Marseille, France

    Patrizia Carrieri

  4. Liver Unit, Vall d’Hebron University Hospital, Vall d’Hebron Institute for Research, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain

    Juan M. Pericàs

  5. Johns Hopkins University-Pompeu Fabra University Public Policy Center, Barcelona, Spain

    Juan M. Pericàs

  6. Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain

    Dana Ivancovsky-Wajcman & Jeffrey V. Lazarus

  7. Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA

    Zobair M. Younossi

  8. CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA

    Jeffrey V. Lazarus

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  1. Shira Zelber-Sagi
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Contributions

S.Z.-S. and D.I.W. researched data for the article. All authors contributed substantially to discussion of the content. S.Z.-S., P.C., J.M.P., Z.M.Y. and J.V.L. wrote the article. S.Z.-S., D.I.W., Z.M.Y. and J.V.L. reviewed and/or edited the manuscript before submission.

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Correspondence to Shira Zelber-Sagi.

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Competing interests

S.Z.-S. has given a presentation for and received support for attending a meeting and/or travel from AbbVie, and has received a consultant fee from Siemens, outside the submitted work. P.C. received research grants by MSD and Intercept in the last 5 years unrelated to this work. J.M.P. reports having received consulting fees from Boehringer-Ingelheim, MSD and Novo Nordisk. He has received speaking fees from Gilead, Intercept and Novo Nordisk, and travel expenses from Gilead, Rubió, Pfizer, Astellas, MSD, CUBICIN and Novo Nordisk. He has received educational and research support from Madrigal, Gilead, Pfizer, Astellas, Accelerate, Novartis, Abbvie, ViiV and MSD, all outside the submitted work. D.I.-W. has no potential competing interests to disclose. Z.M.Y. acknowledges consulting fees from Intercept, Cymabay, Boehringer Ingelheim, Bristol Myers Squibb, GSK, Novo Nordisk, AstraZeneca, Siemens, Madridgal, Merck, Ipsen and Abbott, outside the submitted work. J.V.L. acknowledges grants and speaker fees from AbbVie, Echosens, Gilead Sciences, Moderna, MSD, Novo Nordisk and Roche Diagnostics to his institution, grants from Boehringer-Ingelheim, GSK and Madrigal to his institution, speaker fees from Janssen and ViiV, and consulting fees from AbbVie, Echosens, GSK Novavax and Pfizer, outside the submitted work.

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Zelber-Sagi, S., Carrieri, P., Pericàs, J.M. et al. Food inequity and insecurity and MASLD: burden, challenges, and interventions. Nat Rev Gastroenterol Hepatol (2024). https://doi.org/10.1038/s41575-024-00959-4

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