STRIVE: The Southern Liver Health Study

North Carolina State University


The Southern Liver Health Study (STRIVE) aims to determine whether exposure to environmental contaminants such as Cadmium, either alone or with other toxic metals and per- and poly-fluoroalkyl substances (PFAs), increases the risk of progression from early-stage liver disease to hepatocellular carcinoma (HCC), the most common type of liver Cancer.

Hepatocellular carcinoma is one of few cancers with a rising incidence that disproportionally affects ethnic minorities and rural residents. However, known risk factors including viral hepatitis, fatty liver disease and cirrhosis cannot fully explain these disparities. Environmental contaminants such as Cadmium are common. Cadmium is ranked in the top ten chemicals of concern by the World Health Organization and can cause Cancer in animals. The STRIVE study will use a group of 16,000 participants to assess whether exposure to multiple common environmental contaminants increases liver Cancer risk, whether risk differentially impacts rural and ethnic minorities, and whether epigenetic mechanisms mediate these associations.

The Strive study will be the first large-scale effort to longitudinally determine the link between environmental contaminants, liver disease and Cancer in a residentially and ethnically diverse population.

STRIVE will address some of our most pressing questions in the field of liver diseases and the environment. STRIVE will expand our understanding of the health impacts of chronic exposure to multiple PFAs. STRIVE will also examine how exposures to PFAs and other toxic metals often experienced by the general population impact risk of HCC and liver fibrosis. These interactions between Environmental Exposures and Cancer we learn more about from the STRIVE study can then be used to inform intervention efforts and policy decisions.

Who will be involved?

The study will include two sub-groups made up of 16,000 males and females. The participants will be at least 40 years old and live in two Southeastern states, North Carolina, and Georgia.

Environmental Exposures of Interest

What physical, chemical, biological, or behavioral exposures is STRIVE focusing on?

  • PFAs
    • “PFAS are widely used, long lasting chemicals, components of which break down very slowly over time. Scientific studies have shown that exposure to some PFAs in the environment may be linked to harmful health effects in humans and animals”
  • Metals, particularly Cadmium
    • Cadmium is a natural element found in tiny amounts in air, water, soil, and food. All soils and rocks, including coal and mineral fertilizers, contain some Cadmium. Most Cadmium used in the United States is extracted during the production of other metals such as zinc, Lead, and copper. Cadmium does not corrode easily and has been used to manufacture batteries, pigments, metal coatings, and plastics.”

Outcomes of Interest

What is STRIVE trying to do and find out about through this study?

  • Epigenetic markers
  • Progression from Nonalcoholic Fatty Liver Disease (NAFLD) to liver fibrosis and Hepatocellular carcinoma (HCC)

STRIVE Principal Investigators

Cathrine Hoyo, PhD, MPH
Cynthia Ann Moylan, MD
Joellen Schildkraut, PhD, MPH
Melissa Troester, PhD