Confronting a metabolic epidemic: understanding liver health and how to prevent, diagnose, and manage liver disease | Julia Wattacheril, M.D., M.P.H.

**Peter Attia** (0:11)
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My guest this week is Dr. Julia Wattacheril. Julia specializes in non-alcoholic fatty liver disease, as well as all forms of hepatitis, chronic liver disease and liver cancer, in addition to being a hepatologist who takes care of patients pre and post liver transplantation. Her research interests include hepatic steatosis, insulin resistance, gut hormones and metabolic liver disease in adults.
Julia is an associate professor of medicine and the director of the metabolic dysfunction associated steatotic liver disease program, the Center for the Liver Disease and Transplantation Program at Columbia University Medical Center. Julia earned her MD and completed her residency at Baylor College of Medicine, followed by a fellowship in gastroenterology at Vanderbilt University, where she also earned a master's in public health. Julia then completed a second fellowship in transplant hepatology at Columbia University before becoming and attending there where she is today. In this episode, we start by speaking about the basic physiology and the four functions of the liver, the history of liver disease and liver transplantation and the details of acute versus chronic liver injury. We speak about alcohol-related injury and what it is about the mechanism and metabolism of ethanol that is problematic for the liver. We look at what the optimal levels for liver function tests and liver enzymes might be in a blood test. And Julia explains in fantastic detail what AST and ALT, two very common measurements that we talk about a lot and that you all have undoubtedly seen on your blood test, what do these do in the cell? What do they refer to? And what is it about their elevation that we should or shouldn't be worried about? We then discuss how to improve metabolic health in relation to the liver and why the liver is truly the mothership of all organs. Lastly, Julia outlines the four major stages of liver disease, discussing the risk, treatment options, and the importance of early diagnosis. So without further delay, please enjoy my conversation with Dr. Julia Wattacheril.
Hey, Julia, thank you so much for joining me today. Very important topic and very relevant topic, both in the narrow scope of what I do clinically, and I think the broader scope of what many clinicians do, and frankly, what anybody listening needs to be mindful of, given the epidemic we're about to discuss. But why don't you tell folks a little bit about your training, what it means to be a hepatologist, and what led you there?

**Julia Wattacheril** (3:36)
Sure. Thanks for having me, and thanks for being concerned about the liver.
So I am a transplant hepatologist, so my clinical hat is about 50% divided into liver transplant and 50% divided into general liver care. How I got to that path, so I did medical school in Houston at the Baylor College of Medicine residency there as well, a GI fellowship at Vanderbilt in Nashville, and then my transplant fellowship at Columbia. When it comes to sort of my faculty time division, I tend to focus on Masold or Nafold as it used to be called. And so metabolism and a nexus with endocrinology is also a big focus of mine.

**Peter Attia** (4:16)
So let's take a step back maybe and just give folks a sense of what the liver does.
People have probably heard me say this before, but it's always worth repeating. The liver is this essential organ for which we don't have extracorporeal support. That's just a fancy word that means outside of body support. So if a person's lungs don't work, we saw this a lot during COVID, but obviously we see this all the time, you have extracorporeal support. You have a ventilator that can do the job of the lung for a temporary period of time, hours, weeks, even months.
Believe it or not, if the heart doesn't work, we have extracorporeal support in terms of intra-rheoric balloon pumps or even ventricular assist devices. And obviously if the kidneys don't work, we have extracorporeal support in the form of dialysis. Now, I'm not suggesting any of these things are a substitute for the real thing, but they're remarkable bridges that save many lives. And yet, Julia, we don't have anything that even remotely resembles extracorporeal support for the liver. So we have this essential organ, and yet if it is injured, we don't even have a way to bridge people to transplantation. Anything you want to say about that? I mean, is that just kind of a staggering feature, I think, of this organ?