For centuries, in many cultures, larger body size has been seen as a marker of prosperity, fertility, and social status. But in today’s world, this perception is colliding with a stark reality: obesity is increasingly linked to food insecurity, poor nutrition, and preventable chronic diseases such as metabolic dysfunction-associated steatotic liver disease (MASLD) and diabetes type 2.

On World Obesity Day 2025, we explore the paradox of modern malnutrition: Why are food-insecure communities disproportionately affected by MASLD? How do socioeconomic disparities, aggressive marketing, and low food literacy contribute to an unhealthy cycle of liver disease? And, most importantly, what can be done to break the link between food inequity and metabolic disease?

To help answer these critical questions, we will answer three key questions that contributed to our recent review “Food inequity and insecurity and MASLD: burden, challenges, and interventions” (Nature Reviews Gastroenterology & Hepatology).

Key Questions for the Researcher:

If obesity was historically seen as a sign of wealth and prosperity, why is it now linked to poor health outcomes like MASLD?

In June 2013, the American Medical Association (AMA) recognised obesity as a chronic disease with multifactorial aetiology, including genetics, metabolism, environment, lifestyle, and behavioural components. This, in turn, has substantially shifted how obesity is viewed, underpinning complex risk factors rather than just lifestyle choices. 

Obesity is closely related to additional metabolic diseases such as type 2 diabetes and MASLD. People living with obesity face a 3.5 times higher risk of developing MASLD, compared to those living with a normal weight. MASLD is characterised by fat accumulation within the liver (hepatic steatosis) without secondary causes (e.g., significant alcohol or drug intake). Without adequate care, MASLD can progress to an inflammatory phase known as metabolic dysfunction-associated steatohepatitis (MASH), fibrosis and cirrhosis. 

MASLD is the most common liver disease globally, and on 19 April 2025, World Liver Day will have the theme 'Food is Medicine'.

How does food insecurity contribute to liver disease, and what role do unhealthy diets play in MASLD?

Food insecurity refers to inconsistent access to enough food for a healthy, active life; it is a major structural determinant of health. Beyond food quantity, food insecurity is also related to food quality; in other words, it can represent the limited availability of affordable nutritious food and even water. This could mean that a person is overweight, yet experiencing food insecurity because of the low-quality food being consumed. 

Food insecurity is prevalent in socially deprived communities and negatively affects their nutritional choices and health. Take, for example, when healthy foods like vegetables, fruits, nuts, legumes, olive oil, and fish are expensive or scarce, but fast food is easily obtainable. Western diets have become characterised by high consumption of ultra-processed food, fast food, soft drinks and alcohol, which are associated with worse metabolic health including MASLD as well. When the built and social environments promote the adoption of a Western diet over the recommended Mediterranean diet (or similar plant-based dietary pattern), it increases the risk of MASLD at the individual level. 

People experiencing food insecurity often face psychological stress and self-stigma, which can lead to emotional eating, increased alcohol consumption, and even fewer job opportunities. These factors may further worsen food insecurity and negatively impact metabolic health. 

What can we do to address the link between food insecurity and MASLD?

There are only a few studies investigating the association between food insecurity and MASLD, most of them were conducted in the United States. Thus, the first priority should be strengthening research efforts to underscore the social and environmental determinants of MASLD, as was previously indicated in a global research agenda. In our review, we outlined essential actions and evidence-based initiatives to address MASLD, liver disease as a whole and food insecurity. 

Here are some examples of required actions: 

Policy and environmental changes 

• Increase taxes for unhealthy food and reduce taxes for healthy food
• Restrict advertising and marketing of unhealthy food and beverages
• Reformulate unhealthy foods
• Safe outdoor green spaces for physical activity
• Front-off-pack food labeling including the number of added sugar teaspoon
• Prioritise public health interests concerning food
• Walkable access to affordable healthy foods

 Healthcare and community strategies 

• Routinely screen for food insecurity
• Incorporate socioeconomic inequities and food insecurity into clinical practice guidelines
• Offer economic incentives for healthy foods
• Offer healthy school and workplace lunches
• Promote healthy lifestyle community initiatives
• Provide patients and those at risk with reliable and clear information on healthy lifestyle choices
• Provide or refer for mental health screening and care

We must undertake a multi-level approach that engages clinicians, public health and community experts, patient organisations, and policy-makers as emphasised in the global action priorities agenda. By implementing the recommended actions and strengthening the evidence base, we can improve patient care and better address the high MASLD burden globally.