Low utilization of nutrition referrals in patients with non-alcoholic fatty liver disease further impacted by the COVID-19 pandemic

Background: Non-alcoholic fatty liver disease (NAFLD) affects an estimated 25% of the world's population yet lacks FDA approved treatment. Numerous studies have demonstrated that weight loss improves NAFLD histology. Limited data are available regarding rates of formal nutrition counseling in NAFLD patients. We aimed to assess utilization of nutrition consultation in a large, university hospitalbased NAFLD clinic, with special focus on the impact of the COVID-19 pandemic on our referral patterns. Methods: We retrospectively evaluated patients with NAFLD seen in hepatology clinic from 3/1/19 - 2/28/21. NAFLD was identified using ICD-10 codes. We defined the COVID era as starting on 3/16/20, when shelter in place orders began. All patients seen in our clinic have access to a nutritionist, without charges to the patient or their insurance. Nutrition appointments were conducted exclusively via video or telephone in the post-COVID era. Results: We included 1168 patients with NAFLD;602 (52%) were seen pre-COVID and 566 (48%) post-COVID. The median age was 58 (IQR 48-66), 49% were female, 88% English-speaking, and 50% with private insurance. 134 patients (11%) were seen by a nutritionist;80 (13%) pre- and 54 (10%) post-COVID era. Patients seen in the post-COVID era were younger (p=0.0299) and more likely to have an active MyChart account (p<0.001). There were no significant differences in gender, language, or insurance (Table). In univariable analyses, non-English speaking status, lack of active MyChart account, and post-COVID era were associated with decreased likelihood of completing a nutrition appointment, but not age, race, or insurance type. In multivariable models, post-COVID era (OR 0.57, 95%CI 0.38-0.83), female gender (OR 1.48, 95%CI 1.01-2.16), non-English speaking (OR 0.37, 95% CI 0.15-9.4) and no active MyChart account (OR 0.38, 95%CI 0.23-0.62) remained associated with lower likelihood of a nutrition appointment;race and insurance type were not significant in this model. Conclusion: We have demonstrated that despite open access to formal nutrition counseling in a NAFLD clinic, this occurs rarely. The COVID era has worsened this aspect of care, with non-English speaking patients and those without access to technology for telehealth being more deeply affected. Future studies should further explore the impact of nutrition counseling on achieving weight loss while also implementing interventions to equalize access in the era of telehealth medicine.