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These health mediators should be considered along with individual SDOH in clinical care and healthcare quality and equity improvement, a large retrospective study of adults with MASLD at a multi-state healthcare institution concluded.
Across quartiles, patients in the most disadvantaged neighborhoods (according to home addresses) vs the least disadvantaged had worse outcomes and were also disproportionately Hispanic, Black, and Native American/Alaska Native, more often Spanish-speaking in primary language, and more often uninsured or on Medicaid, according to Karn Wijarnpreecha, MD, MPH, of the Division of Gastroenterology and Hepatology at University of Arizona College of Medicine–Phoenix, and colleagues writing in Clinical Gastroenterology and Hepatology.
Even after adjustment for measures in the Social Deprivation Index (SDI), the incidence of death, cirrhosis, diabetes mellitus (DM), and major adverse cardiovascular events (MACE) was higher in Native American/Alaska Native patients compared with their non-Hispanic White counterparts. The SDI is a composite measure of seven demographic characteristics from the American Community Survey, with scores ranging from 1 to 100 and weighted based on characteristics from national percentile rankings.
Aligning with the growing prevalence of obesity and DM, MASLD has increased substantially over the past three decades, and is now the leading cause of chronic liver disease in this country and the world.
This rise in prevalence has underscored health disparities in MASLD and prompted research into linkd between liver disease and SDOH, defined as the conditions under which people are born, grow, live, work, and age. These are fundamental drivers of health disparities, including those in MASLD.
Study Details
Primary outcomes were MASLD burden, mortality, and comorbidities by neighborhood SDOH, assessed using the SDI in cross-sectional and longitudinal analyses.
A total of 69,191 adult patients (more than 50% female) diagnosed with MASLD were included, 45,003 of whom had at least 365 days of follow-up. They were treated from July 2012 to June 2023 in Banner Health Systems, a network that includes primary-, secondary-, and tertiary-care centers in Arizona, Colorado, Wyoming, Nevada, Nebraska, and California.
The median follow-up time was 48 months. Among patients across SDI quartiles (age range 49 to 62 years), 1390 patients (3.1%) died, 902 (2.0%) developed cirrhosis, 1087 (2.4%) developed LRE, 6537 (14.5%) developed DM, 2057 (4.6%) developed cancer, and 5409 (12.0%) developed MACE.
Those living in the most disadvantaged quartile of neighborhoods compared with the least had the following higher odds:
- cirrhosis, adjusted odds ratio [aOR], 1.42 (P < .001)
- any cardiovascular (CVD) disease, aOR, 1.20 (P < .001),
- coronary artery disease, aOR, 1.17 (P < .001)
- congestive heart failure, aOR, 1.43 (P < .001)
- cerebrovascular accident, aOR, 1.19 (P = .001)
- DM, aOR, 1.57 (P < .001)
- hypertension, aOR, 1.38 (P < .001).
They also had increased incidence of death (adjusted hazard ratio [aHR], 1.47; P < .001), LRE (aHR, 1.31; P = .012), DM (aHR, 1.47; P < .001), and MACE (aHR, 1.24; P < .001).
The study expands upon previous SDOH-related research in liver disease and is the largest analysis of neighborhood-level SDOH in patients with MASLD to date. “Our findings are consistent with a recent study by Chen et al of over 15,900 patients with MASLD in Michigan that found neighborhood-level social disadvantage was associated with increased mortality and incident LREs and CVD,” Wijarnpreecha and colleagues wrote.
“Beyond screening patients for individual-level SDOH, neighborhood-level determinants of health should also be considered, as they are important mediators between the environment and the individual,” they added, calling for studies to better understand the specific neighborhood SDOH that drive the disparate outcomes. In practice, integration of these measures into medical records might inform clinicians which patients would benefit from social services or help guide quality improvement projects and community partnerships.
Wijarnpreecha had no conflicts of interest to disclose. Several coauthors reported research support, consulting/advisory work, or stock ownership for various private-sector companies.
The sprectrum of steatotic liver disease (SLD) including metabolic dysfunction associated steatotic liver disease (MASLD) is increasing in the United Statues. 38% of adults and 7-14% of children currently have MASLD and it is projected that by 2040 the prevalence rate for MASLD will be higher than 55% in US adults. Fortunately, most will not develop serious liver disease. However, even a small subset is impacted, significant liver related morbidity and mortality will be the result.
Yet, concentrating only on the liver misses the substantial impact of other metabolic outcomes associated with MASLD. Equally important, at risk MASLD is treatable with lifestyle modifications, pharmacotherapy and surgical options which improve liver related outcomes, metabolic complications, and all-cause mortality. When over half of the US has a disease that requires individuals to navigate a complex care pathway that includes screening, staging, and risk modification across multiple metabolic conditions, any factor that can help identify those in need for targeted interventions is paramount. And personalization that allows someone to effectively traverse the care pathway allows for the most successful outcome.
Social determinants of health (SDOH) are complex but not insurmountable. By recognizing the contribution of SDOH, studies can be designed to discover which factors drive disparate outcomes on a granular level. This can then support funding and policy changes to address these elements. It is already well established that food insecurity is associated with both prevalence of MASLD and liver-related mortality. Policies to address the issues related to poverty can be prioritized and their impact measured.
This study also highlights the importance of needs by neighborhood. Culture has an impact on diet which is inextricably linked to MASLD. Acculturation, or the process of adapting to a new culture, is associated with poor health, physical inactivity, and poor diet but is also recognized. Western diets are high in saturated fat and refined carbohydrates which then increase risk of obesity and MASLD. In neighborhoods where culturally tailored interventions can improve health outcomes, community-based programs are imperative. In conclusion, a holistic approach that acknowledges and integrates cultural practices and preferences into MASLD prevention and management strategies can improve treatment adherence and outcomes, particularly for high-risk populations.
Nancy S. Reau, MD, AGAF, is professor and section chief of hepatology in the Division of Digestive Diseases and Nutrition at Rush University, Chicago. She has no disclosures in relation to this commentary.
The sprectrum of steatotic liver disease (SLD) including metabolic dysfunction associated steatotic liver disease (MASLD) is increasing in the United Statues. 38% of adults and 7-14% of children currently have MASLD and it is projected that by 2040 the prevalence rate for MASLD will be higher than 55% in US adults. Fortunately, most will not develop serious liver disease. However, even a small subset is impacted, significant liver related morbidity and mortality will be the result.
Yet, concentrating only on the liver misses the substantial impact of other metabolic outcomes associated with MASLD. Equally important, at risk MASLD is treatable with lifestyle modifications, pharmacotherapy and surgical options which improve liver related outcomes, metabolic complications, and all-cause mortality. When over half of the US has a disease that requires individuals to navigate a complex care pathway that includes screening, staging, and risk modification across multiple metabolic conditions, any factor that can help identify those in need for targeted interventions is paramount. And personalization that allows someone to effectively traverse the care pathway allows for the most successful outcome.
Social determinants of health (SDOH) are complex but not insurmountable. By recognizing the contribution of SDOH, studies can be designed to discover which factors drive disparate outcomes on a granular level. This can then support funding and policy changes to address these elements. It is already well established that food insecurity is associated with both prevalence of MASLD and liver-related mortality. Policies to address the issues related to poverty can be prioritized and their impact measured.
This study also highlights the importance of needs by neighborhood. Culture has an impact on diet which is inextricably linked to MASLD. Acculturation, or the process of adapting to a new culture, is associated with poor health, physical inactivity, and poor diet but is also recognized. Western diets are high in saturated fat and refined carbohydrates which then increase risk of obesity and MASLD. In neighborhoods where culturally tailored interventions can improve health outcomes, community-based programs are imperative. In conclusion, a holistic approach that acknowledges and integrates cultural practices and preferences into MASLD prevention and management strategies can improve treatment adherence and outcomes, particularly for high-risk populations.
Nancy S. Reau, MD, AGAF, is professor and section chief of hepatology in the Division of Digestive Diseases and Nutrition at Rush University, Chicago. She has no disclosures in relation to this commentary.
The sprectrum of steatotic liver disease (SLD) including metabolic dysfunction associated steatotic liver disease (MASLD) is increasing in the United Statues. 38% of adults and 7-14% of children currently have MASLD and it is projected that by 2040 the prevalence rate for MASLD will be higher than 55% in US adults. Fortunately, most will not develop serious liver disease. However, even a small subset is impacted, significant liver related morbidity and mortality will be the result.
Yet, concentrating only on the liver misses the substantial impact of other metabolic outcomes associated with MASLD. Equally important, at risk MASLD is treatable with lifestyle modifications, pharmacotherapy and surgical options which improve liver related outcomes, metabolic complications, and all-cause mortality. When over half of the US has a disease that requires individuals to navigate a complex care pathway that includes screening, staging, and risk modification across multiple metabolic conditions, any factor that can help identify those in need for targeted interventions is paramount. And personalization that allows someone to effectively traverse the care pathway allows for the most successful outcome.
Social determinants of health (SDOH) are complex but not insurmountable. By recognizing the contribution of SDOH, studies can be designed to discover which factors drive disparate outcomes on a granular level. This can then support funding and policy changes to address these elements. It is already well established that food insecurity is associated with both prevalence of MASLD and liver-related mortality. Policies to address the issues related to poverty can be prioritized and their impact measured.
This study also highlights the importance of needs by neighborhood. Culture has an impact on diet which is inextricably linked to MASLD. Acculturation, or the process of adapting to a new culture, is associated with poor health, physical inactivity, and poor diet but is also recognized. Western diets are high in saturated fat and refined carbohydrates which then increase risk of obesity and MASLD. In neighborhoods where culturally tailored interventions can improve health outcomes, community-based programs are imperative. In conclusion, a holistic approach that acknowledges and integrates cultural practices and preferences into MASLD prevention and management strategies can improve treatment adherence and outcomes, particularly for high-risk populations.
Nancy S. Reau, MD, AGAF, is professor and section chief of hepatology in the Division of Digestive Diseases and Nutrition at Rush University, Chicago. She has no disclosures in relation to this commentary.
These health mediators should be considered along with individual SDOH in clinical care and healthcare quality and equity improvement, a large retrospective study of adults with MASLD at a multi-state healthcare institution concluded.
Across quartiles, patients in the most disadvantaged neighborhoods (according to home addresses) vs the least disadvantaged had worse outcomes and were also disproportionately Hispanic, Black, and Native American/Alaska Native, more often Spanish-speaking in primary language, and more often uninsured or on Medicaid, according to Karn Wijarnpreecha, MD, MPH, of the Division of Gastroenterology and Hepatology at University of Arizona College of Medicine–Phoenix, and colleagues writing in Clinical Gastroenterology and Hepatology.
Even after adjustment for measures in the Social Deprivation Index (SDI), the incidence of death, cirrhosis, diabetes mellitus (DM), and major adverse cardiovascular events (MACE) was higher in Native American/Alaska Native patients compared with their non-Hispanic White counterparts. The SDI is a composite measure of seven demographic characteristics from the American Community Survey, with scores ranging from 1 to 100 and weighted based on characteristics from national percentile rankings.
Aligning with the growing prevalence of obesity and DM, MASLD has increased substantially over the past three decades, and is now the leading cause of chronic liver disease in this country and the world.
This rise in prevalence has underscored health disparities in MASLD and prompted research into linkd between liver disease and SDOH, defined as the conditions under which people are born, grow, live, work, and age. These are fundamental drivers of health disparities, including those in MASLD.
Study Details
Primary outcomes were MASLD burden, mortality, and comorbidities by neighborhood SDOH, assessed using the SDI in cross-sectional and longitudinal analyses.
A total of 69,191 adult patients (more than 50% female) diagnosed with MASLD were included, 45,003 of whom had at least 365 days of follow-up. They were treated from July 2012 to June 2023 in Banner Health Systems, a network that includes primary-, secondary-, and tertiary-care centers in Arizona, Colorado, Wyoming, Nevada, Nebraska, and California.
The median follow-up time was 48 months. Among patients across SDI quartiles (age range 49 to 62 years), 1390 patients (3.1%) died, 902 (2.0%) developed cirrhosis, 1087 (2.4%) developed LRE, 6537 (14.5%) developed DM, 2057 (4.6%) developed cancer, and 5409 (12.0%) developed MACE.
Those living in the most disadvantaged quartile of neighborhoods compared with the least had the following higher odds:
- cirrhosis, adjusted odds ratio [aOR], 1.42 (P < .001)
- any cardiovascular (CVD) disease, aOR, 1.20 (P < .001),
- coronary artery disease, aOR, 1.17 (P < .001)
- congestive heart failure, aOR, 1.43 (P < .001)
- cerebrovascular accident, aOR, 1.19 (P = .001)
- DM, aOR, 1.57 (P < .001)
- hypertension, aOR, 1.38 (P < .001).
They also had increased incidence of death (adjusted hazard ratio [aHR], 1.47; P < .001), LRE (aHR, 1.31; P = .012), DM (aHR, 1.47; P < .001), and MACE (aHR, 1.24; P < .001).
The study expands upon previous SDOH-related research in liver disease and is the largest analysis of neighborhood-level SDOH in patients with MASLD to date. “Our findings are consistent with a recent study by Chen et al of over 15,900 patients with MASLD in Michigan that found neighborhood-level social disadvantage was associated with increased mortality and incident LREs and CVD,” Wijarnpreecha and colleagues wrote.
“Beyond screening patients for individual-level SDOH, neighborhood-level determinants of health should also be considered, as they are important mediators between the environment and the individual,” they added, calling for studies to better understand the specific neighborhood SDOH that drive the disparate outcomes. In practice, integration of these measures into medical records might inform clinicians which patients would benefit from social services or help guide quality improvement projects and community partnerships.
Wijarnpreecha had no conflicts of interest to disclose. Several coauthors reported research support, consulting/advisory work, or stock ownership for various private-sector companies.
These health mediators should be considered along with individual SDOH in clinical care and healthcare quality and equity improvement, a large retrospective study of adults with MASLD at a multi-state healthcare institution concluded.
Across quartiles, patients in the most disadvantaged neighborhoods (according to home addresses) vs the least disadvantaged had worse outcomes and were also disproportionately Hispanic, Black, and Native American/Alaska Native, more often Spanish-speaking in primary language, and more often uninsured or on Medicaid, according to Karn Wijarnpreecha, MD, MPH, of the Division of Gastroenterology and Hepatology at University of Arizona College of Medicine–Phoenix, and colleagues writing in Clinical Gastroenterology and Hepatology.
Even after adjustment for measures in the Social Deprivation Index (SDI), the incidence of death, cirrhosis, diabetes mellitus (DM), and major adverse cardiovascular events (MACE) was higher in Native American/Alaska Native patients compared with their non-Hispanic White counterparts. The SDI is a composite measure of seven demographic characteristics from the American Community Survey, with scores ranging from 1 to 100 and weighted based on characteristics from national percentile rankings.
Aligning with the growing prevalence of obesity and DM, MASLD has increased substantially over the past three decades, and is now the leading cause of chronic liver disease in this country and the world.
This rise in prevalence has underscored health disparities in MASLD and prompted research into linkd between liver disease and SDOH, defined as the conditions under which people are born, grow, live, work, and age. These are fundamental drivers of health disparities, including those in MASLD.
Study Details
Primary outcomes were MASLD burden, mortality, and comorbidities by neighborhood SDOH, assessed using the SDI in cross-sectional and longitudinal analyses.
A total of 69,191 adult patients (more than 50% female) diagnosed with MASLD were included, 45,003 of whom had at least 365 days of follow-up. They were treated from July 2012 to June 2023 in Banner Health Systems, a network that includes primary-, secondary-, and tertiary-care centers in Arizona, Colorado, Wyoming, Nevada, Nebraska, and California.
The median follow-up time was 48 months. Among patients across SDI quartiles (age range 49 to 62 years), 1390 patients (3.1%) died, 902 (2.0%) developed cirrhosis, 1087 (2.4%) developed LRE, 6537 (14.5%) developed DM, 2057 (4.6%) developed cancer, and 5409 (12.0%) developed MACE.
Those living in the most disadvantaged quartile of neighborhoods compared with the least had the following higher odds:
- cirrhosis, adjusted odds ratio [aOR], 1.42 (P < .001)
- any cardiovascular (CVD) disease, aOR, 1.20 (P < .001),
- coronary artery disease, aOR, 1.17 (P < .001)
- congestive heart failure, aOR, 1.43 (P < .001)
- cerebrovascular accident, aOR, 1.19 (P = .001)
- DM, aOR, 1.57 (P < .001)
- hypertension, aOR, 1.38 (P < .001).
They also had increased incidence of death (adjusted hazard ratio [aHR], 1.47; P < .001), LRE (aHR, 1.31; P = .012), DM (aHR, 1.47; P < .001), and MACE (aHR, 1.24; P < .001).
The study expands upon previous SDOH-related research in liver disease and is the largest analysis of neighborhood-level SDOH in patients with MASLD to date. “Our findings are consistent with a recent study by Chen et al of over 15,900 patients with MASLD in Michigan that found neighborhood-level social disadvantage was associated with increased mortality and incident LREs and CVD,” Wijarnpreecha and colleagues wrote.
“Beyond screening patients for individual-level SDOH, neighborhood-level determinants of health should also be considered, as they are important mediators between the environment and the individual,” they added, calling for studies to better understand the specific neighborhood SDOH that drive the disparate outcomes. In practice, integration of these measures into medical records might inform clinicians which patients would benefit from social services or help guide quality improvement projects and community partnerships.
Wijarnpreecha had no conflicts of interest to disclose. Several coauthors reported research support, consulting/advisory work, or stock ownership for various private-sector companies.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY