#405 ‒ AMA #88: Metabolic liver health: how to assess risk, catch dysfunction early, and prevent or reverse liver disease

**Peter Attia** (0:10)
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Welcome to Ask Me Anything AMA episode 88 Today we are talking about the liver, and specifically its role in metabolic health. This is a topic that suffers from a strange mismatch. On the one hand, the liver is one of the most metabolically important organs in the body. It is the mastermind sitting at the center of how we handle glucose, fat and cholesterol. And on the other, most of the public conversation about the liver is about detoxes, cleanses and supplements, while the questions that actually matter go unasked. So we're going to focus on one of the liver's main functions, how it serves as the centerpiece of the whole body metabolism, and walk through how to tell whether yours is under stress, why that matters, and what actually moves the needle once you need to act. So specifically, we're going to cover why the liver is the so-called canary in the coal mine for metabolic dysfunction, the four stages of progression from metabolic stress to fibrosis, and which stages are reversible, why normal liver enzymes can be misleading, and what we actually use to detect and stage risk, what interventions work once risk or disease is identified, plus an honest look at whether any liver supplements are worth taking. If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch a sneak peek of the video on our YouTube page. So without further delay, welcome to AMA episode 88

**SPEAKER_2** (2:27)
Peter, welcome to another AMA. How are you doing?

**Peter Attia** (2:30)
Very good, thanks.

**SPEAKER_2** (2:31)
Awesome. So today, we're doing the whole episode around one topic, which is the liver and metabolic health. In the past, you've described the liver as the quote unquote primary in the coal mine for metabolic dysfunction. So I think it'd be helpful to start with kind of talking about what you mean by that and why you think the liver is so important.

**Peter Attia** (2:51)
Well, the liver sits sort of at the center of systemic metabolism for every macronutrient, glucose, fat, protein, as well as cholesterol. And by the way, let's not forget ethanol or alcohol there as well. So it's also one of the very first places to both promote and respond to stress from anywhere in the system. If circulating triglycerides are high, the liver gets involved. If glucose regulation is deteriorating, the liver is involved. If ApoB or LDL cholesterol is climbing, the liver made those particles.
And the flip side is equally true. If we look at the liver and see that it's under stress, we know that these metabolic systems are also under stress.
It's a two-way mirror between systemic metabolic health and what's happening in the liver. And that's also why I think about liver disease less about a stand-alone organ problem. Dysfunction of the liver is more of a parallel expression of systemic metabolic dysfunction. The leading cause of death in people with liver disease isn't liver failure. It's cardiovascular disease. Because a liver under metabolic stress is overproducing ApoB-containing particles and amplifying the insulin resistance that drives atherosclerosis throughout the body.
And so that's why this is a metabolic episode as much as a liver one. And I guess we should also name it up front. When we're talking about fatty liver disease, we're talking about a disorder that is estimated to affect more than 38 percent of the world's adult population, which is hard to believe. This isn't something that happens to some unfortunate person that you'll never meet. It will happen to nearly anyone in the developed world who isn't paying some attention.

**SPEAKER_2** (4:46)
And I think it's worth kind of early on talking about what the liver does, right? So I think for a lot of people, when they think of the liver, they usually think about processing alcohol. So before we get too much into metabolic disease, can you frame in a little more detail what the liver is doing in the body?
Sure.

**Peter Attia** (5:04)
And you're right, the alcohol framing dominates, and that's a bit of an undersell. As our past guest, Julia Watercherell says, the liver has over 300 functions, which is sort of staggering. Obviously, we're not going to talk about many of those today, but I find it useful to conceptualize all of those as fitting into four main categories. So the first is detoxification. The liver breaks down alcohol, just as it would break down virtually any toxin that makes its way into the body, from food, drink, pharmaceuticals, inhalation. Any toxin that reaches the blood, the liver plays a central role in clearing it.