suggesting the presence of other causes
of disease. Some of these patients were more
likely to have had clinical or biochemical features
of fatty liver disease (obesity) or the metabolic
syndrome (e.g., type 2 diabetes). In populationbased
cohort studies in the United States, Scandinavia,
Taiwan, and Japan,12-14 hepatocellular
carcinoma was 1.5 to 2.0 times as likely to develop
in obese persons as in those who were not
obese. Several case–control studies and a few cohort
studies have shown that, on average, hepatocellular
carcinoma is twice as likely to develop in
persons with type 2 diabetes as compared with
those who do not have diabetes.15,16 Nonalcoholic
fatty liver disease, which is present in up to 90%
of all obese persons and up to 70% of persons with