We read with great interest the comprehensive review by Dirjayanto et al. titled “Nutrition in Hepatocellular Carcinoma: Pathophysiological Insights, Impact, and Implications for Clinical Practice” 1. The authors are commended for their thorough synthesis of current evidence on the multifaceted role of malnutrition in HCC and for emphasizing the urgent need for early nutritional assessment and intervention across the disease continuum. The authors rightly highlight the high prevalence of sarcopenia and malnutrition in HCC patients and their association with poor clinical outcomes. The integration of validated screening tools such as GLIM, NRS-2002, and PG-SGA into routine care is a critical step forward. However, we would like to raise two key points that merit further discussion and may guide future research and clinical implementation. First, although the review outlines general macronutrient and micronutrient recommendations, it largely reflects a “one-size-fits-all” approach. Given the metabolic heterogeneity of HCC—especially across different etiologies such as NASH, ALD, and viral hepatitis—there is a pressing need for precision nutrition strategies. For instance, NASH-related HCC is often accompanied by insulin resistance and systemic inflammation, where carbohydrate quality and glycemic load may be more relevant than total caloric intake 2. Future studies should explore metabolomic and microbiomic profiling to tailor interventions based on individual metabolic phenotypes. Second, the review appropriately emphasizes the importance of multidisciplinary care, yet it underplays the practical barriers to implementing nutritional interventions in real-world settings, particularly in resource-limited environments 3. Issues such as lack of trained dietitians, limited access to oral nutritional supplements, and inconsistent screening practices are common in many liver centers globally. We advocate for the development of simplified, cost-effective protocols that can be adapted to different healthcare systems, potentially leveraging digital health tools or tele-nutrition platforms. Furthermore, although the authors discuss the role of exercise in mitigating sarcopenia, they stop short of proposing integrated nutrition–exercise frameworks that could be embedded into prehabilitation programs prior to surgery or locoregional therapy. Emerging evidence supports the synergistic effects of targeted nutrition and resistance training in improving muscle mass and functional capacity in cirrhotic patients 4, and this deserves greater emphasis in HCC management. In conclusion, the review by Dirjayanto et al. is a timely and valuable contribution to the field. It sets the stage for a paradigm shift in how we view nutrition—not just as supportive care, but as a modifiable determinant of survival and quality of life in HCC. We hope that future guidelines will move beyond generalized recommendations toward individualized, evidence-based, and context-sensitive nutritional strategies. Yours sincerely. The authors have nothing to report. The authors declare no conflicts of interest. I will be able to provide data as needed.
Xie et al. (Thu,) studied this question.