Mapping preventable risks: Obesity, alcohol, and hepatocellular carcinoma in the U.S.

528 Background: Hepatocellular carcinoma (HCC) is a major public health concern in the U.S., with obesity and alcohol consumption as key modifiable drivers. Geographic variation in these risk factors and cancer burden may influence clinical outcomes, which remain poorly defined. An understanding of regional and state-level disparities is essential for prevention, risk assessment, and equitable policy. Methods: We analyzed Behavioral Risk Factor Surveillance System (BRFSS) and CDC WONDER data to assess obesity, excessive alcohol use (EAU), and HCC across U.S. regions and states from 2018 to 2022. EAU was defined as heavy drinking (≥15 drinks/week men, ≥8 women) or binge drinking (≥5 drinks/occasion men, ≥4 women). Obesity was BMI ≥30. Outcomes included prevalence of obesity, EAU, and self-reported HCC (BRFSS), and age-adjusted HCC incidence (CDC WONDER). Weighted prevalence was estimated using BRFSS survey design, and logistic regression models generated adjusted odds ratios (aORs) controlling for age, sex, race/ethnicity, income, insurance, and primary care physician (PCP) visit. Stata software was used for analysis and p<0.05 was considered significant. Results: From 2018 to 2022, HCC incidence declined in all regions, with the largest decline in the West (–1.5/100,000) and the least in the South (–0.8/100,000). In 2022, the South had the highest incidence (7.8/100,000) of HCC. Incidence was higher among males, Hispanics, and American Indian/Alaska Natives, with the highest state-level rates in the District of Columbia (13.3/100,000) and Texas (12.0/100,000). Obesity rose significantly in all regions. In 2022, obesity was highest in the South (35.7%) and lowest in the West (29.2%) (p<0.001). State-level prevalence was greatest in West Virginia (41.2%) and Mississippi (41.0%). Odds of obesity were higher in Blacks (aOR 1.45, 95% CI 1.4,1.5), females (aOR 1.03, 95% CI 1.01,1.05), and Medicaid enrollees (aOR 1.16, 95% CI 1.1, 1.2) (all p<0.003). Higher income was protective. EAU increased in all regions except the South, where it remained stable. In 2022, prevalence was highest in the South (68.1%) and West (65.8%) (p<0.0001), with West Virginia reporting the highest state-level prevalence (76.2%). Higher odds were observed among American Indian/Alaska Natives (aOR 1.51, 95% CI 1.36,1.69), females (aOR 1.06, 95% CI 1.04, 1.09), Medicaid enrollees (aOR 1.31, 95% CI 1.25,1.37), and those without PCP (aOR 1.31, 95% CI 1.11,1.55) (all p<0.001). Higher income was protective. The South region accounted for the largest share of self-reported liver cancer (37.0%). Conclusions: The South carries the heaviest burden of risk factors and cases, highlighting the need for region-specific strategies targeting obesity reduction, alcohol control, and improved screening to address preventable inequities in HCC.