302 - Confronting a metabolic epidemic: how to prevent, diagnose, & manage liver disease

View show notes here: bit.ly/3Kr5a4Z
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Julia Wattacheril is a physician scientist & director of the Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) program at Columbia University Irving Medical Center. In this episode, Julia delves deep into the complex world of liver health, beginning with a foundational overview of liver physiology. She provides an in-depth look at how alcohol impacts liver function, breaking down the metabolism of ethanol & its detrimental effects. Julia then shifts the focus to understanding liver function tests & optimal enzyme levels, providing a detailed explanation of AST & ALT & elucidating why fluctuations in these levels may or may not be concerning. She provides a primer on the four major stages of liver disease, discussing risk & emphasizing the importance of early diagnosis. Julia highlights the role of liver disease in increasing the risk of cancer & cardiovascular disease & covers in detail the various strategies for diagnosing, treating, & preventing the progression of liver disease. Dr. Wattacheril’s views expressed in this conversation reflect her own, not those of her institution.
We discuss:
0:00:00-Intro
0:01:52-Julia’s training, importance of liver health, & innovations of hepatology
0:08:14-The crucial functionality of the liver & its four most essential functions
0:13:36-Liver injuries: understanding causal factors & the progression to liver diseases & cancer
0:26:03-How the liver metabolizes nutrients & what happens in the presence of excess calories
0:35:39-Methods of diagnosing liver disease
0:43:45-The poisonous nature of ethanol
0:51:19-Varied responses to alcohol, damaging effects of alcohol beyond the liver, & advising patients on their alcohol consumption
1:03:59-Liver enzymes AST & ALT-interpreting levels, lifestyle factors that affect them, & diagnostic approaches
1:20:39-Interpreting liver function tests for fatty liver disease, & diagnosing liver pathologies, particularly in children versus adults
1:26:45-Comprehensive liver health assessments via imaging & various diagnostic tools to prevent overlooking potential liver pathologies
1:35:32-Impact of recreational drugs, statins, & other medications on liver function test results
1:39:49-Shifting nomenclature from NAFLD to MASLD
1:46:40-Pathophysiology of MASLD, the need for proactive screening, & the significance of liver fat percentage
1:53:46-Screening for rare conditions alongside common metabolic diseases associated with fatty liver
1:56:50-Practical strategies for managing MAFLD
2:05:10-Impact of fructose consumption on liver health & the challenges of disentangling its effects from obesity & insulin resistance
2:10:20-The potential of GLP-1 agonists for the treatment of MASLD
2:13:31-4 stages of liver disease
2:18:21-Increased cancer & heart disease risk associated with early-stage MAFLD
2:26:18-Emerging drugs & therapies for addressing fat accumulation & fibrosis related to MAFLD
2:33:33-Takeaways
--------
About:
The Peter Attia Drive is a deep-dive podcast focusing on maximizing longevity, & all that goes into that from physical to cognitive to emotional health. With over 90 million episodes downloaded, it features topics including exercise, nutritional biochemistry, cardiovascular disease, Alzheimer’s disease, cancer, mental health, & much more.
Peter Attia is the founder of Early Medical, a medical practice that applies the principles of Medicine 3.0 to patients with the goal of lengthening their lifespan & simultaneously improving their healthspan.
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[@PeterAttiaMD]

In this episode, we discuss: 0:01:52-Julia’s training, importance of liver health, & innovations of hepatology 0:08:14-The crucial functionality of the liver & its four most essential functions 0:13:36-Liver injuries: understanding causal factors & the progression to liver diseases & cancer 0:26:03-How the liver metabolizes nutrients & what happens in the presence of excess calories 0:35:39-Methods of diagnosing liver disease 0:43:45-The poisonous nature of ethanol 0:51:19-Varied responses to alcohol, damaging effects of alcohol beyond the liver, & advising patients on their alcohol consumption 1:03:59-Liver enzymes AST & ALT-interpreting levels, lifestyle factors that affect them, & diagnostic approaches 1:20:39-Interpreting liver function tests for fatty liver disease, & diagnosing liver pathologies, particularly in children versus adults 1:26:45-Comprehensive liver health assessments via imaging & various diagnostic tools to prevent overlooking potential liver pathologies 1:35:32-Impact of recreational drugs, statins, & other medications on liver function test results 1:39:49-Shifting nomenclature from NAFLD to MASLD 1:46:40-Pathophysiology of MASLD, the need for proactive screening, & the significance of liver fat percentage 1:53:46-Screening for rare conditions alongside common metabolic diseases associated with fatty liver 1:56:50-Practical strategies for managing MAFLD 2:05:10-Impact of fructose consumption on liver health & the challenges of disentangling its effects from obesity & insulin resistance 2:10:20-The potential of GLP-1 agonists for the treatment of MASLD 2:13:31-4 stages of liver disease 2:18:21-Increased cancer & heart disease risk associated with early-stage MAFLD 2:26:18-Emerging drugs & therapies for addressing fat accumulation & fibrosis related to MAFLD 2:33:33-Takeaways

[@JuliMoodyStunts]

Great discussion I learned a lot Possibly explore more in the future the injury part due to hard training in not onlyvthe liver levels but other changes

[@daniellubowa595]

Thanks alot both!

[@laza6141]

It's incredible that we can get all this information for free , thank you both.

[@user-ou8pe9it8j]

It's free o Medical and physiopathology, pathology BOOKS

[@oolala53]

@@user-ou8pe9it8j are you implying that people should be willing to read those books on their own and just skip KZbin?

[@drgaffneybestfoot]

Amazingly brilliant hepatologist and still able to share her vast valuable knowledge in a humble way with the public . Thank-you!

[@user-nh1bz6kh1t]

An INVALUABLE public service, delivered clearly and professionally. THANK YOU to both Julia & Peter for adding immensely to my understanding of the liver and its role in human biology.

[@kaceeboxers3580]

70ish female, non drinker, type 1 diabetic with non diabetic A1C, 22 BMI. Did major pressure washing (literally tons of real stone on our house) to rid mold/mildew from the mortar joints. Also used a long extension part of the time and was holding it above my head. Had scheduled bloodwork the following Monday and my AST was 3 points over normal. My ALT was also increased but still in normal range. I explained to my doctor what I had been doing and why I thought the increases were there. To be on the safe side, had a fibro scan done and results were normal. Three months later, retested and AST was 19 (10-35 QUEST, FL) and ALT was 14 (6-29). Following two tests results were the same. I believe the muscle strain and mildew caused both my liver enzymes to increase. Next time I will wear a mask. The muscle strain is just part of the job.

[@ukaserex]

So...the "teaser", I guess it's called. The first opening part, she talks about involving endocrinologist, and other doctors on the care of this one patient. What kind of practice does this? I can't imagine ANY insurance covering that kind of expense. One patient, with cardiologist, endocrinologist and hepatology expert and however many other experts...for one patient? This just doesn't exist for most people. Does it? The out of pocket cost has to be in the thousands, if it does.

[@joeymcbain4537]

It's very difficult to be knowledgeable, articulate, beautiful and humble at the same time. Well done Julia, thank you Peter

[@szghasem]

I find Julia as impressive and fascinating as the liver's vital role is in sustaining life. She is articulate and incredibly knowledgeable. Thank you, Peter, for sharing her insights with your audience.

[@daniellubowa595]

She is marvellous!

[@pxp175]

Ya, she makes Petter sound like an average dude. I think this woman might be the most eloquent speaker I've heard in English.

[@MT-sq3jo]

I am delighted that she did most of the talking, which was very informative and I learned a lot of new things from her. It easily beats out Peter’s rumbling monologue 😂

[@PaulieShortcuts]

Great interview. I started watching “liver disease” a guy on KZbin who’s got massive liver and pancreas damage to convince me to start caring for myself better.

[@kwilliams1958]

Thank you, Doctors...to be able to listen to dedicated professionals talk about such intense health issues is invaluable.

[@paddy3622]

this is one of the best discussions. our poor livers. the damage most kids(high school/college) do drinking is scary. myself included.

[@ug8179]

I know right? Now my kids high school is selling Starbucks style coffee with load of sugars 😢 it’s scary.

[@lewynld]

Most interesting episode I have seen in a while. I hope Peter has guests that cover other organs

[@weightlossat50]

My god I wish she were my Dr. So knowledgeable and genuinely concerned with healing

[@miriamsuarez9543]

The amount of times that I needed to go back to rehear the info. So valuable Thank you for such a great content!

[@jeffcampbell1280]

Wow, fantastic interview, very interesting, great information, thank you both!

[@allisonfalin8854]

The amount of liver disease that I and my docs and fellow NP in GI clinic is mind blowing. It’s overtaking IBS.

[@neilquinn]

Actually kind of surprised at the total alcohol intake being that high for Peter. Obviously labs aren't that bad but given carcinogenic effects seems like a lot. I mostly stopped drinking and really don't miss it much at all. Counter being that the liver is soooo resilient.

[@lindacronise5613]

This is a fantastic interview. I learned a lot about the liver, thank you!

[@peggyon1]

Wow, she is incredibly knowledgeable.

[@wsteele5864]

It is amazing how much I learned today. Thank you so much.

[@yomain7227]

Name one thing you learned.

[@wsteele5864]

@@yomain7227 To a moron troll?

[@941charna]

Question: My husband is 77 years old. 6’3” tall -160 lbs ( has lost weight due to cutting sugar and carbs since beginning of year (2024) he was 175 lbs. History of very high B/P since 20 years old. Treated successfully with meds. On statins - since late 80s - Lipitor 80mg per day - his triglycerides are still too high and his HDLs are too low. Liver function tests within normal limits - liver dr said compensated liver disease caused by Alpha1 Antitripsin deficiency. Last year (April 2023) had two cancerous nodules from liver radio waved out. We asked for evaluation of current state of his liver - but liver doctor said - “can’t tell in cases where patient has alpha1 because it confuses things” Now, Latest thing is - 2 heart attacks and double bypass in April. Recovering well. We understand the gravity of his situation - his mother (small skinny active wirey woman - died at 90 yrs after lifetime of treated High B/P and also on statins since late 80s. Must have been at least a MZ - BUT spent 5 years in nursing home with Alzheimer’s. He has always complied with all medical advice but never took the initiative to investigate or evaluate his own treatment. I am pushing the situation right now because I want to keep him with me for as long as possible BUT don’t want Alzheimer’s - couldn’t deal with it - neither could he. Please comment on if he should change his statin because we not think it is contributing to his brain fog and perhaps his liver issues. Every day is important to us but not if it contributes to cutting cholesterol in brain and contributes to dementia.

[@angiejohnson8417]

Is there any mention of "meds" and the liver? If not, could anyone provide information on bodily systems and the impact of antidepressants, anti-anxiety medications, stress, gut microbiome and the liver? In teens?

[@patriciarogers2174]

So good When was this recorded, curious due to the references to the pandemic which sounds to be ongoing?

[@vitennis9109]

I am wondering how often there are cases of fatty liver in people with APOB mutations, specifically when the mutatuon results in a disfuncional APOB, where the protein is not able to form VLDL and LDL particles so fat ends up accumulating in the liver. Because APOB is such a large protein, with over 4500 amino acids , I would think the mutations are rather common. Very little testing is done, as almost every physician is only concerned with high LDL and TG and low levels are oddly ignored. I am heterozygous for APOB-32 mutation ( LDL of 25 and TG 30) . I hope you find my question interesting .

[@Emboru]

It is common apparently. 5x liver fat for the same bmi/glucose tolerance curves. Why do I know this? I have fhbl.. 👋. I was in an nih study... they ultrasounded my liver due to risk. My father who I inherited this from went from fatty liver to late fibrosis with normal blood enzymes. I'm really concerned.... and most doctors know almost nothing My ldl normally hovers around 25 as well. We are low even for fhbl. Sigh.

[@ashdgee]

Interesting podcast. I wish we elaborated more on fructose. Like how much is too much? Can eating fruit be dangerous for people already having liver disease etc

[@fabiooliveira788]

Check the "bittersweet truth " by Dr. Pradip

[@phyllis7532]

I would check out Dr Jason Fung who is amazing explaining about fructose. He is a Nephroologist (Kidney Specialist in Canada). He also has a KZbin channel as well. kzbin.info/www/bejne/laClnJejqLeoZrssi=Lk5O9G14ytTTdID5 He has written a few books, which I have all of them. The Complete Guide to Fasting The Obesity Code The Diabetes Code The Cancer Code I wish you good health!

[@phyllis7532]

I would check out Dr Jason Fung who is amazing explaining about fructose. He is a Nephroologist (Kidney Specialist in Canada). He also has a KZbin channel as well. kzbin.info/www/bejne/laClnJejqLeoZrssi=Lk5O9G14ytTTdID5 He has written a few books, which I have all of them. The Complete Guide to Fasting The Obesity Code The Diabetes Code The Cancer Code I wish you good health!

[@phyllis7532]

I would check out Dr Jason Fung who is amazing explaining about fructose. He is a Nephroologist (Kidney Specialist in Canada). He also has a KZbin channel as well. kzbin.info/www/bejne/laClnJejqLeoZrssi=Lk5O9G14ytTTdID5 He has written a few books, which I have all of them. The Complete Guide to Fasting The Obesity Code The Diabetes Code The Cancer Code I wish you good health!

[@pedro.almeida]

Fruit is usually not a problem because of the fiber, but still if you already have a problem, then I would stay away from certain high fructose fruits (eg. Figs) or only consume them in very small portions (eg. Half a fig). And of course no juice whatsoever. Maybe reverse juice if you really feel like you are missing out on fruit.

[@lookswhatsnew8951]

Are elevated liver enzymes from prescribed colestipol or statins , indicative of disease ?

[@sharyhunt9025]

Can you link liver fat to visceral fat? If visceral fat is elevated does that indicate a need for further testing of the potential for fatty liver?

[@rdbm-uo5zt]

Hmm. I asked my doctor about my fatty liver. She said not to worry too much: only in a small percent of individuals, does it go on to later stages. My ALT was 28, and has been around this for decades. She said it was common nowadays.

[@oolala53]

I visited an old friend last summer and somehow the topic of prediabetes came up. She said her doctor said oh everybody has that. She said it in such a cavalier way. As if the doctor was saying, it’s not really a problem. I honestly think that doctors get to the point where they kind of throw up their hands because they keep telling patients to do preventative things and the patients don’t do them. Even when they give them medication a lot of times the patients don’t take the medication. I’m sure it’s frustrating on both sides.

[@smlince]

Choline ever discussed? If so anyone know when? Ty

[@John_in_Oakland]

Would like to know Dr. Wattacheril’s thoughts about the Ayurvedic supplement bhringraj sans the concern about process contamination. That is, a pure, organically produced form of bhringraj.

[@ug8179]

Can low carbs/keto increase your ALT?

[@joerobberechts4547]

Not mentioned here but alcohol at high doses is eliminated via zero-order kinetics. Small increase in dose leads to a big increase in toxicity with zero-order kinetics, because a constant amount of alcohol is eliminated per unit time (1 standard drink per hour) the half life and time it takes to eliminate all the alcohol is massively increased. In other words because alcohol is eliminated by zero-order/ saturation kinetics, it stays in your system longer able to cause damage to liver cells. That’s not the case with caffeine where the amount eliminated depends on the dose, i.e the half life is constant. Make sense?

[@Rrgblitz403]

I am a 21 year old male and have had consistently heightened liver enzymes, though my AST has come into “normal range” at 37. However, ALT is 76. Ive never drank alcohol, exercise and maintain a good diet as well. Did a liver MRI, Wilson’s disease test, autoimmune test, Hep E test, amongst many others and docs are still unable to figure out what’s going on. Everything else has come back normal. Is it possible that individuals can have a higher number level at baseline and still function normally?

[@LastBattlerX]

Do you have a high protein diet?

[@whoatethechocolate]

Those are some scary labs. Peter recommends alt and ast to be under 20.

[@thiagobartolo]

Please can you comment on coenzyme q10?

[@jp7357]

fantastic YT .. I learned a lot. Completely demonstrates Julia knows her s**t.

[@CD318]

Peter Attia ROCKS!

[@soonneyinjules]

Peter parties 🤘🏼

[@lookswhatsnew8951]

What is your opinion of CHEERS RESTORE ?

[@tmchugh]

Sad the amount of people commenting on Peters alcohol intake- if anything, this makes him more relateable and normal. I’m sure he has a great quality of life and enjoys socializing with friends. I guess some listeners would rather he was a total freak- plenty of other people you can listen to who don’t drink, and enjoy crazy diets like only eating red meat 😊

[@sherrygaley4675]

We need a bit of clarity about coffee please. Does drinking it with light cream negate the benefits?

[@lewynld]

Debatable, depending on your health and metabolic status. In other words, if you need the caffeine then the cream is sort of irrelevant. If you are looking for other health benefits then yes, you are better off without the sugar and other proteins.

[@investgrow8857]

As Winston Churchill once said: I have taken more out of alcohol than alcohol, has taken out of me. Not sure what Julia would’ve said as Churchills doctor.

[@endgamefond]

Suplements can cause liver injury? How can we make sure our suplements are safe even from famous brands?

[@Marx1963]

Frequent lab would be my guess- with supplements and without is what I do . Not expensive at all . Good luck

[@user-ou8pe9it8j]

That's why I don't take suplements.

[@pxp175]

Take only what a doctor recommends and not what people on internet recommend. Read up on anything you take.

[@endgamefond]

Peter's most favorite organ: Liver.

[@laza6141]

2:02:15

[@SAntczak2]

Metabolic Derangement is the name of my next punk band.

[@cynthiaberry2019]

Get people to stop drinking alcohol.

[@smooth_pursuit]

And juice

[@nicholeh1280]

Added sugar is a bigger culprit. Sugar addiction is more accepted and joked about. Kids are getting fatty liver disease.

[@ghjong001]

*Bas Rutten has entered the chat...*

[@BigWhitesJourney]

Damn took my comment down… lol

[@OurFamilyInMotion]

I am a bit surprised and disappointed to hear in this episode that Peter is a moderate alcohol drinker. For someone who is usually evidence-based in his decision-making, this is surprising as nearly all the recent high quality data on alcohol is negative in terms of heart disease, cancer, liver disease, neurodegenerative diseases, etc.

[@endgamefond]

He said it's occasional in social gathering settings.

[@user-ou8pe9it8j]

Everything is for *image* and sell something, an ideal, a book, a suplements. No blame to making money.

[@aaronashmann2048]

I think it's great that Peter is transparent with his alcohol usage.

[@TerryHilsberg]

@@user-ou8pe9it8j Attia has in the many years I have been listening to him, thought that alcohol has no safe lower limit. He has argued that he trades off the low level physical harm at low doses against the social benefits he derives from low level consumption. I see no evidence of hypocrisy.

[@nichtsistkostenlos6565]

We all make trade-offs in terms of our enjoyment of life vs. our lifespan. You can optimize your health regimen to the point that you hate your life and then what is even the point of living?

[@allencrider]

I think that hasving 6 to 8 drinks per week is a pathway to addiction.

[@Lolipop59]

No, it's not.

[@allencrider]

@@Lolipop59 Just try and stop. Get a serious, open look at your own situation.

[@mattmathai]

Absolutely not. Rather, it might be for you. It certainly isn't for me. I drink that much. I also have multiple week gaps when I travel and have zero desire to have a drink. I start again when I'm curious about some flavor combination I want to try. (I mix my own cocktails.)

[@allencrider]

@@mattmathai Just give it more time. Alcoholism isn't an instant-on phenomenon.

[@mattmathai]

@@allencrider Nor is it determined by how much you do or don't drink. You're confusing cause and effect. The propensity to suffer from alcoholism can lead to drinking more. That's an entirely different scenario. (And, btw, alcoholism is very much an "instant-on" phenomenon)

[@alexburns2982]

That’s why stay away from meme coins - it’s just noise

[@josephneuwirth1475]

I cannot understand a darn thing that woman says!!

[@paddy3622]

extracorporeal. word of the day. what a great word.