Comment on: global burden and trends of primary liver cancer are attributable to high BMI among hepatitis B patients: based on the 2021 global burden of disease study

Dear editor, In terms of cancer-related deaths, liver cancer ranks third and is the sixth most frequent type of cancer diagnosed globally. Aflatoxin exposure, metabolic syndrome, as well as persistent HBV and HCV infections are the main causes of its high incidence and fatality rates1,2. Primary liver cancer is a common gastrointestinal cancer that presents serious risks to human health and is still very difficult to treat. As a surrogate marker for obesity, high BMI is becoming more widely acknowledged as a separate risk factor for liver cancer, particularly when non-alcoholic fatty liver disease develops into cirrhosis and then hepatocellular carcinoma. On the basis of Global Burden of Disease 2021, Hu et al3 calculated the worldwide disease burden of liver cancer caused by obesity in patients with hepatitis B. They came to the conclusion that hepatitis B patients’ excessive BMI has been contributing to a rising global burden of liver cancer (Table 1 and Table 2). Hepatitis B patients should use tailored preventative strategies aimed against obesity. Table 1 - Global and regional hepatitis B-related ASDR and EAPC associated with high BMI, 1990–2021. location 1990 2021 EAPC (95%CI) Number (95% UI) ASR (95%UI) Number (95% UI) ASR (95%UI) Global 115 459 (44 713–185 296) 2.639 (1.023–4.235) 499 881 (191 910–856 371) 5.74 (2.204–9.84) 2.49 (2.39–2.59) Socio-demographic index (SDI) High SDI 22 883 (9324–38 088) 2.233 (0.913–3.714) 69 943 (28 111–119 087) 4.146 (1.649–7.043) 1.89 (1.7–2.09) High-middle SDI 36 481 (14 012–60 194) 3.474 (1.336–5.726) 150 174 (56 671–272 467) 8.094 (3.08–14.774) 2.67 (2.54–2.79) Middle SDI 37 778 (15 352–59 617) 2.962 (1.198–4.685) 200 547 (78 890–350 630) 6.981 (2.747–12.16) 2.86 (2.73–2.99) Low-middle SDI 11 451 (4125–19 070) 1.551 (0.559–2.582) 54 350 (21 444–92 174) 3.277 (1.279–5.519) 2.28 (2.22–2.34) Low SDI 6728 (2229–12 115) 2.424 (0.796–4.412) 24 582 (8620–41 921) 3.714 (1.305–6.437) 1.17 (1.08–1.25) Region Andean Latin America 774 (294–1463) 3.279 (1.222–6.127) 2904 (1139–5292) 4.676 (1.832–8.589) 0.85 (0.61–1.08) Australasia 272 (96–500) 1.223 (0.432–2.244) 1819 (678–3171) 4.157 (1.535–7.153) 3.93 (3.75–4.11) Caribbean 430 (162–723) 1.547 (0.581–2.618) 1176 (447–2084) 2.212 (0.838–3.902) 0.76 (0.48–1.04) Central Asia 4042 (1439–7084) 7.842 (2.832–13.73) 7186 (2604–13 317) 7.512 (2.742–13.848) −0.62 (−0.79 to −0.45) Central Europe 5183 (1841–9114) 3.424 (1.216–5.99) 6643 (2320–11 830) 3.439 (1.211–6.227) −0.16 (−0.3 to −0.03) Central Latin America 1577 (582–2815) 1.612 (0.593–2.901) 5272 (2122–9141) 2.005 (0.803–3.478) 0.61 (0.29–0.94) Central Sub-Saharan Africa 412 (110–993) 1.416 (0.372–3.412) 2184 (623–5566) 2.815 (0.806–7.051) 1.94 (1.84–2.04) East Asia 46 076 (19 097–74 252) 4.391 (1.822–7.09) 257 954 (97 807–482 233) 12.227 (4.654–22.821) 3.42 (3.25–3.58) Eastern Europe 4826 (1825–8062) 1.722 (0.653–2.869) 9161 (3573–16 146) 2.906 (1.148–5.073) 1.71 (1.37–2.05) Eastern Sub-Saharan Africa 1381 (485–2417) 1.462 (0.511–2.599) 7167 (2488–13 310) 3.101 (1.051–5.806) 2.12 (1.91–2.32) High-income Asia Pacific 8751 (3544–15 037) 4.16 (1.686–7.135) 14 527 (5412–25 440) 4.478 (1.66–7.922) −0.12 (-0.39–0.14) High-income North America 3993 (1554–7083) 1.253 (0.488–2.226) 18 488 (7763 -29 552) 3.317 (1.392–5.303) 3.24 (2.88–3.6) North Africa and Middle East 9924 (3557–17 172) 4.942 (1.776–8.612) 47 075 (18 984 -80 048) 8.722 (3.53–14.865) 1.55 (1.31–1.79) Oceania 290 (101–567) 7.427 (2.585–14.539) 818 (309–1520) 8.144 (3.074–15.057 0.19 (0.02–0.36) South Asia 2501 (985–4150) 0.344 (0.137–0.566) 24 149 (9290–40 400) 1.431 (0.549–2.395) 4.92 (4.74–5.10) Southeast Asia 6633 (2605–11 009) 2.058 (0.806–3.417) 31 975 (12 425–55 964) 4.199 (1.64–7.311) 2.04 (1.75–2.33) Southern Latin America 318 (111–590) 0.675 (0.236–1.255) 1573 (579–2847) 1.906 (0.706–3.446) 3.91 (3.59–4.22) Southern Sub-Saharan Africa 2106 (772–3637) 6.129 (2.278–10.743 9898 (4060–16 736) 14.055 (5.745–23.562) 2.2 (1.51–2.9) Tropical Latin America 1221 (468–2188) 1.113 (0.426–1.995) 5057 (1962–8557) 1.91 (0.742–3.238) 2.08 (1.87–2.28) Western Europe 6948 (2542–12 137) 1.338 (0.491–2.348) 18 326 (6465–32 455) 2.507 (0.891–4.461) 2.02 (1.88–2.17) Western Sub-Saharan Africa 7801 (2626–13 747) 7.407 (2.492–13.183) 26 528 (9988–46 242) 10.13 (3.804–17.535) 0.7 (0.56–0.84) Table 2 - ASMR and EAPC for hepatitis B associated with high BMI globally and regionally from 1990 to 2021. location Number (95% UI) 1990 ASR (95% UI) Number (95% UI) 2021 ASR (95% UI) EAPC (95% CI) Global 3408 (1325–5502) 0.081 (0.032–0.131) 15 698 (6010–26 907) 0.18 (0.069–0.309) 2.60 (2.50 to 2.69) Socio-demographic Index (SDI) High SDI 736 (296–1222) 0.07 (0.028–0.116) 2549 (1041–4329) 0.137 (0.056–0.233) 2.12 (1.94 to 2.3) High-middle SDI 1086 (414–1809) 0.105 (0.04–0.174) 4724 (1781–8537) 0.246 (0.093–0.444) 2.74 (2.63 to 2.85) Middle SDI 1052 (425–1674) 0.089 (0.036–0.144) 6120 (2386–10 479) 0.217 (0.085–0.371) 3.01 (2.88 to 3.14) Low-middle SDI 335 (121–563) 0.049 (0.018–0.084) 1611 (623–2752) 0.103 (0.04–0.175) 2.25 (2.19 to 2.3) Low SDI 196 (64–356) 0.077 (0.025–0.142) 684 (242–1198) 0.114 (0.041–0.201) 1.07 (0.99 to 1.16) Region Andean Latin America 24 (9–43) 0.107 (0.039–0.198) 99 (38–183) 0.165 (0.064–0.302) 1.13 (0.9 to 1.35) Australasia 9 (3–16) 0.038 (0.013–0.07) 65 (24–113) 0.136 (0.051–0.235) 4.08 (3.88 to 4.27) Caribbean 13 (5–22) 0.049 (0.018–0.082) 38 (14–66) 0.07 (0.027–0.124) 0.81 (0.53 to 1.09) Central Asia 123 (44–215) 0.246 (0.089–0.427) 220 (80–410) 0.242 (0.089–0.451) –0.48 (–0.64 to –0.31) Central Europe 177 (62–303) 0.116 (0.041–0.198) 251 (88–444) 0.121 (0.042–0.214) –0.04 (–0.18 to 0.1) Central Latin America 48 (17–85) 0.053 (0.019–0.094) 171 (67–299) 0.067 (0.026–0.117) 0.67 (0.34 to 0.99) Central Sub-Saharan Africa 12 (3–28) 0.044 (0.011–0.106) 60 (17–149) 0.087 (0.025–0.218) 1.93 (1.83 to 2.03) East Asia 1264 (521–2044) 0.128 (0.053–0.207) 7920 (2984–14 386) 0.366 (0.138–0.665) 3.58 (3.43 to 3.73) Eastern Europe 157 (60–264) 0.055 (0.021–0.093) 313 (120–546) 0.094 (0.037–0.162) 1.73 (1.43 to 2.03) Eastern Sub-Saharan Africa 39 (14–70) 0.045 (0.016–0.081) 197 (67–369) 0.095 (0.032–0.188) 2.1 (1.9 to 2.3) High-income Asia Pacific 265 (109–452) 0.126 (0.052–0.215) 554 (213–969) 0.149 (0.056–0.262) 0.2 (–0.03 to 0.43) High-income North America 132 (51–237) 0.04 (0.015–0.071) 678 (282–1099) 0.111 (0.047–0.179) 3.48 (3.14 to 3.82) North Africa and Middle East 300 (108–522) 0.162 (0.057–0.283) 1469 (593–2504) 0.297 (0.118–0.506) 1.7 (1.44 to 1.95) Oceania 8 (3–16) 0.225 (0.078–0.447) 23 (9–42) 0.252 (0.093–0.467) 0.25 (0.09 to 0.41) South Asia 71 (28–116) 0.011 (0.004–0.018) 719 (275–1211) 0.045 (0.017–0.075) 4.99 (4.83 to 5.16) Southeast Asia 180 (70–297) 0.06 (0.023–0.099) 933 (364–1622) 0.128 (0.05–0.22) 2.23 (1.96 to 2.51) Southern Latin America 11 (4–19) 0.023 (0.008–0.041) 56 (20–102) 0.066 (0.024–0.119) 4.03 (3.73 to 4.34) Southern Sub-Saharan Africa 56 (21–97) 0.177 (0.066–0.313) 281 (115–472) 0.434 (0.176–0.728) 2.4 (1.73 to 3.07) Tropical Latin America 35 (13–63) 0.034 (0.013–0.061) 162 (62–279) 0.062 (0.024–0.106) 2.24 (2.04 to 2.44) Western Europe 256 (93–444) 0.047 (0.017–0.081) 731 (265–1292) 0.088 (0.032–0.156) 2.04 (1.91 to 2.17) Western Sub-Saharan Africa 231 (78–411) 0.238 (0.08–0.436) 757 (285–1304) 0.333 (0.125–0.575) 0.79 (0.66 to 0.92) Between 1990 and 2021, both the ASDR and ASMR for liver cancer among hepatitis B patients attributed to high BMI grew dramatically worldwide, a phenomenon linked to demographic changes and population expansion. The medium socio-demographic index (SDI) areas had the highest burden of liver cancer among hepatitis B patients due to high BMI, partly due to particularly concerning rates of rise in rising economies. These results have significant ramifications for public health policy as well as clinical practice. Body weight should be methodically included into the clinical evaluation of liver cancer risk. Particularly for middle-aged and older persons who face the most burdens, healthcare clinicians are urged to frequently assess BMI, give individualized lifestyle counseling, and include weight management into survivorship care programs. From a public health perspective, tailored treatment plans should be developed for individuals with both hepatitis B and high BMI, based on the successful experiences and resource status of SDI in various regions. In order to achieve synergy between obesity management and HBV control, it is crucial to integrate HBV vaccination with basic obesity management in low SDI areas. For instance, this can be achieved by incorporating nutritional guidance and BMI screening at vaccination sites, providing follow-up training for community health workers, and administering antiviral medications simultaneously. To effectively lower the prevalence of liver cancer in middle SDI regions, tiered treatments based on BMI and HBV DNA levels should be formulated, giving priority to high-risk individuals. Enforcing mandatory front-of-pack nutrition labeling with appropriate intake advice, promoting multidisciplinary specialist care, integrating weight management for hepatitis B patients into health insurance systems, and implementing multisectoral strategies encouraging physical activity and a healthy diet are all recommendations for high SDI regions. By 2050, it is predicted that the number of DALYs and deaths linked to high BMI-induced liver cancer will continue to increase. This suggests that in order to lessen the worldwide burden of liver cancer, targeted interventions must continue to be developed and implemented, especially in vulnerable populations and settings with limited resources. This letter was conducted according to Transparency in the reporting of Artificial Intelligence-the TITAN guideline4.