The association of food insecurity with hepatic steatosis in women with and without HIV

Objective: Food insecurity is a risk factor for metabolic dysfunction-associated steatotic liver disease in the general population. However, little is known about the impact of food insecurity on hepatic steatosis among women with (WWH) and without HIV (WWOH). Design: We assessed hepatic steatosis by controlled attenuated parameter (CAP) in decibels/meter (dB/m) and food security status using the U.S. Household Food Security Survey in women without viral hepatitis. Women were categorized as being food secure vs food insecure. Methods: We performed multivariable linear regression analyses to examine the association of food security status with hepatic steatosis. Results: Among 1,473 women (1,064 WWH, 409 WWOH), 20% reported food insecurity. Food insecurity was associated with lower CAP after adjustment for age, race-ethnicity, income, alcohol intake, BMI, insulin resistance, and HIV (CAP difference: -8.6 dB/m, 95% CI: -16.7 to -0.5, p = 0.037). Each 5 kg/m 2 BMI increase was associated with an 18.4 dB/m CAP increase (95% CI: 16.4 to 20.3, p < 0.001); there was no association of HIV serostatus with steatosis. Additionally, there was a significant interaction between food insecurity and BMI: among women experiencing food insecurity, for every 5 kg/m 2 BMI increase, CAP decreased by 6.6 dB/m (95%CI: -12.2 to -1.1, p = 0.02). Conclusions: Food insecurity is prevalent in WWH and, unexpectedly, is associated with less steatosis, in contrast with findings observed in the general population. Additionally, while obesity remains a strong driver of steatosis, food insecurity attenuates the association of BMI with steatosis, particularly at higher BMIs. This study lays the groundwork for future efforts exploring potential mechanistic pathways.