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The proportion of hepatocellular carcinoma (HCC) cases due to NAFLD is expected to increase, paralleling the rise in NAFLD due to the obesity epidemic. Early detection is critical, as it potentially enables curative treatment. Current guidelines recommend ultrasound imaging with or without serum AFP measurement in patients with cirrhosis. Unfortunately, several challenges and barriers impede the effective surveillance of HCC in patients with NAFLD. In this review, we focus on four main challenges and barriers: the scale of the NAFLD epidemic, the lack of accurate risk stratification tools, the limitations of available surveillance tools themselves, and the existing disparities in access to care for chronic liver disease. We describe potential solutions, including public health approaches to obesity, improving clinical risk scores using genomic and metabolomic data, improved imaging techniques and blood-based biomarkers, and focusing on underserved groups with liver disease.