Correlating Neighborhood-level Deprivation to Initial Presentation and Disease Severity in Pediatric Non-alcoholic Fatty Liver Disease

Background: Non-alcoholic fatty liver disease (NAFLD) is a growing issue within the pediatric community. There is a strong correlation between NAFLD and obesity, peripheral insulin resistance, sedentary lifestyle, and genetic predisposition. The evidence suggesting socioeconomic status (SES) as a risk factor for NAFLD is limited. A prior study suggests that children from a more socioeconomically deprived neighborhood present at a younger age, but do not necessarily suffer from more severe pathology. We aim to further characterize the presentation of NAFLD in patients across the spectrum of neighborhood deprivation as well as identify any possible correlation between SES and disease severity at the time of diagnosis. This will allow us to identify a potentially at-risk population that would require targeted interventions for disease prevention and treatment.

Methods: This is a retrospective case-control study of 344 patients with a diagnosis of NAFLD who were seen at The Fatty Liver Clinic at Rady Children’s Hospital between January 2012 and June 2017. Each patient received an Area Deprivation Index (ADI) score representative of their state decile rank for neighborhood deprivation, taking into account income, education, employment, and housing quality. ADI was then correlated to symptomatology, laboratory findings, and histological data at the time of presentation and diagnosis. Data analysis was collected for our sample as a whole, which was then broken down into two groups for comparison: low ADI (5 or below) and high ADI (6 or above).

Results: Our study sample was predominantly male (63.7%) and Hispanic (78.8%). The mean ADI across our entire sample was 6.54 (SD = 6.54, n = 344) with the mean for our low and ADI groups at 3.92 (SD = 1.09, n = 101) and 7.63 (SD = 1.29, n = 243) respectively. Our two ADI groups did not statistically significantly differ between age of presentation or diagnosis, type of presentation, or associated conditions aside from the higher ADI group being 2.014 times more likely to also be diagnosed with low HDL (sig. 0.037, 95% C.I. 1.043-3.887). Mean liver function testing and histopathologic NAFLD Activity Scores (NAS) did not significantly differ between low and high ADI patients. Across the entire sample, ADI was not an independent predictor of either aspartate transaminase (AST), alanine transaminase (ALT), or NAS severity.

Conclusion: Pediatric patients with NAFLD come from the entire spectrum of neighborhood deprivation but on average tend to be above the 50th decile for state-level neighborhood deprivation. There was no difference in presentation characteristics and severity of NAFLD, aside from lower HDL values amongst patients with higher levels of neighborhood deprivation. Area deprivation was not shown to be predictive of more severe disease as assessed by serum liver enzymes and liver biopsy NAFLD activity scores.