Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession

Food inequity and insecurity and MASLD: burden, challenges, and interventions

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.

Socioeconomic Deprivation Weighs Heavily on Liver Fibrosis and Mortality After Hepatitis C Cure (ANRS CO22 Hepather)

Although Hepatitis C virus (HCV) infection can be cured with direct-acting antivirals (DAA), some cured patients face a serious risk of advanced liver damage and early mortality. In order to avoid these two negative health outcomes, it is important to identify and assess related risk factors. Little is currently known about socioeconomic and behavioural factors in this context. Using data from the ANRS CO22 Hepather cohort, we tested for associations between socioeconomic and behavioural factors and (i) advanced liver fibrosis (defined as an FIB-4 > 3.25) assessed longitudinally using a mixed-effects logistic regression model (both the whole population and stratified on advanced liver fibrosis status at the time of HCV cure) and (ii) all-cause mortality (Cox proportional hazards model), during post-HCV cure follow-up. Among 5833 participants cured of HCV, living in poverty was associated with postcure advanced liver fibrosis in participants without this diagnosis at the time of HCV cure (population attributable fraction-PAF-of 8.6%) and with mortality in the whole study population (PAF of 10.6%). The detrimental effects of unhealthy alcohol use and heavy tobacco smoking, as well as the beneficial effect of living with a stable partner were also highlighted. We highlighted the major role of poverty and behavioural factors in advanced liver fibrosis and all-cause mortality in patients cured of HCV. Encouraging linkage to social support services and healthy behaviours after successful DAA treatment could limit morbidity and increase survival in this population. Clinical Trial Registration: ClinicalTrials.gov: NCT01953458.

Material deprivation is associated with liver stiffness and liver-related outcomes in people with HIV

BACKGROUND

Socioeconomic status (SES) is a driver of health disparities and chronic diseases. People with HIV (PWH) are at risk for chronic liver diseases. We evaluated the association between low SES and hepatic outcomes in PWH.

METHODS

We included PWH from a prospective cohort. SES was assessed by the Pampalon material and social deprivation index to classify the cohort into quintiles of deprivation. Multivariable linear regression was used to investigate associations of material and social deprivation with liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) as markers of hepatic fibrosis and steatosis, respectively. Incidence of outcomes was evaluated through survival analysis.

RESULTS

Among the 804 PWH included, 45% and 72% were living in areas of the highest material and social deprivation, respectively. Materially deprived PWH were more frequently female and of non-white ethnicity and had higher prevalence of metabolic comorbidities. After adjustments, material deprivation correlated with increased LSM (β = 1.86, 95% CI 0.53-3.17) but not with CAP (β = 6.47, 95% CI -5.55-18.49). Patients were observed for a median follow-up of 3.8 years. Incidence of liver-related events was higher in most materially deprived compared to most privileged PWH (hazard ratio 3.03, 95% CI 1.03-8.92), while there was no difference in extrahepatic outcomes or all-cause mortality. Social deprivation showed no association with either LSM or clinical outcomes.

CONCLUSIONS

Living in materially deprived neighbourhoods as a proxy for lower SES, is associated with LSM and liver-related events in PWH. Future strategies should explore mechanisms underlying these relationships and whether enhanced material security improves hepatic outcomes.

Role of sex in liver tumor occurrence and clinical outcomes: A comprehensive review

Clinical research on sex-based differences in the manifestations, pathophysiology, and prevalence of several diseases, including those affecting the liver, has expanded considerably in recent years. Increasing evidence suggests that liver diseases develop, progress, and respond to treatment differently depending on the sex. These observations support the concept that the liver is a sexually dimorphic organ in which estrogen and androgen receptors are present, which results in disparities between men and women in liver gene expression patterns, immune responses, and the progression of liver damage, including the propensity to develop liver malignancies. Sex hormones play protective or deleterious roles depending on the patient's sex, the severity of the underlying disease, and the nature of precipitating factors. Moreover, obesity, alcohol consumption, and active smoking, as well as social determinants of liver diseases leading to sex-related inequalities, may interact strongly with hormone-related mechanisms of liver damage. Drug-induced liver injury, viral hepatitis, and metabolic liver diseases are influenced by the status of sex hormones. Available data on the roles of sex hormones and gender differences in liver tumor occurrence and clinical outcomes are conflicting. Here, we critically review the main gender-based differences in the molecular mechanisms associated with liver carcinogenesis and the prevalence, prognosis, and treatment of primary and metastatic liver tumors.

Inequities in primary liver cancer in Europe: The state of play

Given the increasing burden of liver cancer in Europe, it is crucial to investigate how social determinants of health (SDoH) affect liver cancer risk factors and access to care in order to improve health outcomes equitably. This paper summarises the available evidence on the differential distribution of liver cancer risk factors, incidence, and health outcomes in the European Economic Area and the United Kingdom from an SDoH perspective. Vulnerable and marginalised populations have low socio-economic and educational levels and are the most affected by liver cancer risk factors. Reasons for this include varied access to hepatitis B virus vaccination and limited access to viral hepatitis B and C screening, harm reduction, and treatment. Additionally, alcohol-related liver disease remains highly prevalent among individuals with low education, insecure employment, economic instability, migrants, and deprived populations. Moreover, significant variation exists across Europe in the proportion of adults with steatotic liver disease, overweight/obesity, and diabetes, based on geographical area, gender, socio-economic and educational background, and density of ultra-processed food outlets. Inequities in cirrhosis mortality rates have been reported, with the highest death rates among individuals living in socio-economically disadvantaged areas and those with lower educational levels. Furthermore, insufficient healthcare access for key populations with primary liver cancer is influenced by complex healthcare systems, stigmatisation, discrimination, low education, language barriers, and fear of disclosure. These challenges contribute to inequities in liver cancer care pathways. Future studies are needed to explore the different SDoH-interlinked effects on liver cancer incidence and outcomes in European countries. The ultimate goal is to develop evidence-based multilevel public health interventions that reduce the SDoH impact in precipitating and perpetuating the disproportionate burden of liver cancer in specific populations.

Socio-economic vulnerability and deaths of despair in Brazilian counties

Over the past few years, there has been a progressive increase in premature deaths attributable to suicide, drug overdose, and alcohol-related liver disease that impact life expectancy. Regarding the relationship with contextual effects, the evidence is developing, especially in countries with a peripheral economy, as is the case of Brazil. We carried out an analysis aimed at estimating the relationship between socioeconomic insecurity and deaths due to despair in Brazilian cities. We used 5,570 counties' data to create clusters concerning socioeconomic development and then analyzed age-adjusted mortality rates (ASMR) from each of them and compared them using the ANOVA test. Cluster analysis generated two groups of Brazilian municipalities. DoD rates are consistently higher in the group that experiences more deprivation. However, considering differences between 2010 and 2019, the increase in rates was higher in the group with less deprivation experience (48.82 % vs. 39.53 %) We verified an existing gap between the clusters before the beginning of economic stagnation in 2010 The gap between those two groups decreased from 20.58 % (p < 0.001) in 2010 to 14.03 % in 2019 (p = 0.034). The conjuncture of economic crises creates mortality differentials in certain population groups. Also, significant inequalities explain how causes of death from despair affect different subpopulations. Our first approach assessed this assumption, and we could check those differentials at an ecological level. Public policies should focus on reducing the difference in mortality from despair between higher and lower socioeconomic strata.

Development and Performance Evaluation of an IoT-Integrated Breath Analyzer

Although alcohol consumption may produce effects that can be beneficial or harmful, alcohol consumption prevails among communities around the globe. Additionally, alcohol consumption patterns may be associated with several factors among communities and individuals. Numerous technologies and methods are implemented to enhance the detection and tracking of alcohol consumption, such as vehicle-integrated and wearable devices. In this paper, we present a cellular-based Internet of Things (IoT) implementation in a breath analyzer to enable data collection from multiple users via a single device. Cellular technology using hypertext transfer protocol (HTTP) was implemented as an IoT gateway. IoT integration enabled the direct retrieval of information from a database relative to the device and direct upload of data from the device onto the database. A manually developed threshold algorithm was implemented to quantify alcohol concentrations within a range from 0 to 200 mcg/100 mL breath alcohol content using electrochemical reactions in a fuel-cell sensor. Two data collections were performed: one was used for the development of the model and was split into two sets for model development and on-machine validation, and another was used as an experimental verification test. An overall accuracy of 98.16% was achieved, and relative standard deviations within the range from 1.41% to 2.69% were achieved, indicating the reliable repeatability of the results. The implication of this paper is that the developed device (an IoT-integrated breath analyzer) may provide practical assistance for healthcare representatives and researchers when conducting studies involving the detection and data collection of alcohol consumption patterns.

Applying an equity lens to liver health and research in Europe

Liver disease is a major cause of premature death and disability in Europe. However, morbidity and mortality are not equally distributed in the population. In spite of this, there are few studies addressing the issue of health inequalities in Europe. In this Public Health Corner article, we compare the research conducted on health inequalities in Europe to other settings and highlight the main differences based upon an extensive review of the literature. We report that only 10.2% of studies were led by European institutions or conducted in European populations and that certain topics such as alcohol-related liver disease are largely overlooked. In addition, we discuss the relevance of including a health equity lens when conducting clinical, epidemiological and health systems' research in liver disease and set out the basic requirements to tackle health inequalities in liver disease in Europe.

Alcohol Consumption Patterns: A Systematic Review of Demographic and Sociocultural Influencing Factors

Background: Excessive alcohol consumption has negative effects not only on the drinkers’ health but also on others around them. Previous studies suggest that excessive alcohol consumption can be related to a combination of factors such as age, family background, religiosity, etc. Investigating and clarifying these roots of alcohol consumption is crucial so that the right type of interventions can be designed in a specific and targeted manner. Objectives: This work was conducted as a systematic review to reveal the factors associated with alcohol consumption and to heighten the understanding of the differences among various communities and segments of the population regarding their usage of alcohol. Data sources: A systematic search of Web of Science, PubMed, ScienceDirect, and Google Scholar was performed. Results: Forty-five studies were included in the review after excluding irrelevant records and duplicates. Conclusions: Alcohol consumption patterns can be associated with several factors related to communities and individuals, and our review revealed demographic factors, including age and proximity to alcohol outlets, as well as social factors, including family background, socioeconomic background, and religious influence. These findings can be used to establish a guideline for further studies in understanding alcohol consumption patterns among individuals according to their personal characteristics and sociocultural backgrounds.