Lower health literacy tied to worse MASLD

Lower health literacy was associated with more severe liver disease and metabolic dysfunction among adults with metabolic dysfunction–associated steatotic liver disease (MASLD), according to a cross-sectional pilot study of 101 patients.

Reporting in Gastro Hep Advances, investigators led by first author, Alana Saddic, MSN, NP, AGACNP-BC, of the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health at Virginia Commonwealth University (VCU) School of Medicine, Richmond, and colleagues reported that poorer scores across multiple domains of the validated Health Literacy Questionnaire (HLQ) correlated with higher liver stiffness measurements, greater hepatic steatosis, and higher body mass index.

“Health literacy is an important determinant of outcomes for many chronic diseases," Saddic told GI & Hepatology News. “However, health literacy in MASLD patients has not been well studied. This pilot study establishes that health literacy should be further studied as a contributor to health outcome in MASLD patients.”

The researchers enrolled 101 adults with MASLD seen in a tertiary hepatology clinic affiliated with VCU Health System in 2023. MASLD was defined by the presence of metabolic risk factors and evidence of steatosis on imaging, controlled attenuation parameter (CAP) measurement or biopsy, in the absence of other causes. Participants completed the 44-item HLQ, which assesses nine domains of health literacy. Clinical and laboratory data were abstracted from the medical record.

The mean age was 56.9 years; 61.4% were women and 75.2% were White. Mean liver stiffness measurement (LSM) by transient elastography was 10.6 kPa, mean CAP was 297 dB/m and mean Fibrosis-4 Index (FIB-4) was 2.18. The mean BMI was 34.7 kg/m², and 43.6% had type 2 diabetes.

On the HLQ, the highest scoring domain in part 1 (scale 1–4) was “feeling understood and supported by health care providers” (mean 3.43). The lowest was “actively managing my health” (2.98), including the lowest individual item score for making time to be healthy (2.78). In part 2 (scale 1–5), “understanding health information well enough to know what to do” scored highest (4.12), while “navigating the health care system” scored lowest (3.83).

In bivariate analyses, lower ability to actively manage health was associated with greater steatosis and obesity. CAP correlated inversely with actively managing health (r = −0.29; P = .01) and social support (r = −0.30; P < .01). BMI correlated inversely with actively managing health (r = −0.38; P < .01) and social support (r = −0.20; P < .05).

Liver stiffness was inversely correlated with the ability to understand health information (r = −0.24; P < .05). Hemoglobin A1C was inversely associated with the ability to find good health information (r = −0.259; P < .05), although this association did not persist after adjustment.

In multivariable regression adjusting for age, race, education, insurance status and type 2 diabetes, actively managing health remained strongly associated with BMI (β = −4.83; P < .001). Actively managing health was also positively associated with FIB-4 (β = 0.998; P = .025). Associations between HLQ domains and HbA1C were no longer significant after adjustment.

Education level was linked to health literacy and disease severity. Higher education correlated with better scores in finding (r = 0.25; P = .01), appraising (r = 0.24; P = .01) and understanding health information (r = 0.34; P < .001). Patients with more than four years of college had higher HLQ scores and lower LSM values compared with those with high school education or less.

When the researchers performed hierarchical clustering, 93% of participants fell into two main groups: high health literacy and low health literacy. The cluster characterized by lower education had significantly lower scores across all nine HLQ domains (all P < .001) and higher mean LSM (13.38 kPa vs 7.47 kPa; P = .025). CAP and BMI trended higher in the lower-literacy cluster, though differences were not statistically significant.

No significant differences in HLQ scores were observed by race, age or gender. Patients with public insurance had higher scores for actively managing health compared with those with private insurance (P = .05).

The authors noted several limitations of the study, including its single-center design, predominantly Caucasian sample, and cross-sectional nature, which precludes the ability to show cause and effect.

“Future studies in larger and more diverse cohorts followed prospectively will be needed to definitively establish to what degree health literacy modulates disease severity, what interventions may improve health literacy and if meeting health literacy needs will improve the patient journey with the disease and long-term outcomes,” Saddic said.

Funding for the study was provided by grants from Novo Nordisk and the NIDDK as well as intramural funds from the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health and the National Center for Advancing Translational Sciences. Saddic disclosed holding stock options in Eli Lilly and McKesson. 

 GI & Hepatology News invited first author Alana Saddic, MSN, NP, AGACNP-BC, to share her perspective on the study’s implications.

When you had all the data in front of you, was there a finding, or perhaps more than one, that surprised you?

Saddic: We suspected that lower health literacy would be related to lower level of education, and we did, indeed, find that. It was similarly validating to see that lower education level and lower health literacy were also related to worsened liver and metabolic health. I suspected there would be more variety of profiles in the cluster analysis, so I was surprised that there were only two clusters seen: one with lower level of education, lower health literacy scores in all dimensions and worse metabolic/liver health versus the other with higher level of education, higher health literacy scores in all dimensions, and better metabolic/liver health in several dimensions.

I was also surprised to see that, in general, patients felt able to understand health information well enough to know what to do but they had trouble actively managing their health. This shows there is a disconnect between knowing/understanding what to do and having the ability to do so. This deserves exploration in future studies.

How might the findings influence clinical practice?

Saddic: We found that lower scores on several dimensions of health literacy (including appraising, finding, and understanding health information) were related to lower education levels. We also found that lower education levels were related to higher liver stiffness measurement and worsened other metabolic parameters. Some healthcare practices routinely assess level of education in their social determinates of health screening, without directly assessing health literacy. If a patient with MASLD is recognized to have a lower education level, they may be identified as being at higher risk for low health literacy and worsened liver/metabolic health. Perhaps the clinician could tailor their approach to help these patients with finding, appraising, and understanding health information.

We also found that, on average, patients had the most difficulty with actively managing their health. Particularly, making time to be healthy. Furthermore, the health literacy dimension of actively managing my health and social support for health were negatively correlated with BMI and level of fat in the liver (CAP score). Interventions to help patients actively manage their health could be an area of focus to help patients with the lifestyle modifications (weight loss, diet and exercise) inherent to improving their MASLD. Efforts to improve social support for patients might also prove effective. Partnering with with behavioral health and/or dietician support may be a way to target improvement in these areas.

Additionally, we found that, on average, patients had difficulty with navigating the healthcare system. This is an important consideration because MASLD does not occur in isolation; it is part of a constellation of metabolic dysfunction requiring the care of often multiple specialists (cardiology, nephrology, hepatology, PCP, etc.). As such, being able to navigate the healthcare system is especially important for these patients.