Racial and ethnic differences in diet quality and food insecurity among adults with fatty liver and significant fibrosis: a U.S. population‐based study

BACKGROUND: Food insecurity affects diet quality (DQ) and is associated with non‐alcoholic fatty liver disease (NAFLD). While racial and ethnic disparities in NAFLD exist, the relationship between food insecurity and DQ by race and ethnicity is unknown. AIM: To examine the relationship between food insecurity and DQ in adults with NAFLD and significant fibrosis by race and ethnicity in a nationally representative cohort METHODS: We performed a cross‐sectional analysis of U.S. adults (≥20 years) in the National Health and Nutrition Examination Survey 2017–2018 with vibration‐controlled transient elastography (VCTE), DQ, and food security (FS) measurements. NAFLD and significant fibrosis were defined using validated VCTE cut‐offs. We assessed total and component DQ by the healthy eating index (HEI)‐2015, with poor scores defined as <25th percentile. We used multivariable linear and logistic regression to examine associations of FS and race/ethnicity with DQ. RESULTS: Of 1351 adults with NAFLD (17% food insecure; 248 with fibrosis), mean (standard error [SE]) DQ score was 49 (1) and 47(1.2) for food secure and insecure groups, respectively. Mean (SE) DQ was lowest for White (47[1.1]), followed by Black (49[0.9]), Hispanic (50[1.2]) and Asian persons (56[2.1]). In multivariable models, there was an inverse relationship between FS and DQ, although this did not reach statistical significance (estimated difference [coef]:‐1.8 mean HEI score, 95% CI: −4.3–0.7; p = 0.14). Adjusted mean DQ scores were higher for Black (coef:+3.0, 95% CI:0.5–5.5; p = 0.02), Asian (coef:+7.4, 95% CI:3.4–11.5; p = 0.001) and Hispanic (coef: +4.3, 95% CI: 0.6–7.9; p = 0.03) compared to White persons. Greatest differences in DQ components by food security status were seen in White persons. CONCLUSION: Among adults with NAFLD, White persons had poorer DQ than other races/ethnicities. The influence of food insecurity on DQ may be potentiated in this group. Exploration of the sociocultural factors influencing DQ is needed to mitigate NAFLD disparities.