Dangerous but silent fatty liver disease is exploding in prevalence.

Thanks for watching episode #137 of the Doctor podcast program, and I'm your host, Doctor Robert Sicard. We'd appreciate if you could subscribe to and follow Doctor podcasts and like and repost this episode. It will help us get great guests like we have today. Today's topic is a very important topic but unfortunately not discussed enough. It's the subject of fatty liver and its consequences such as liver failure, cirrhosis, liver cancer and sometimes a need for liver transplant. With us today, we have two great guests, a patient who has experienced all these consequences of fatty liver unfortunately.

And we also have a physician who is one of the world's leading experts on fatty liver. Our first guest is Terry Milton. Terry is a liver cancer survivor and liver transplant recipient from 2022, about four years ago and she's from Houston, TX. She progressed from fatty liver disease diagnosed decades ago to stage 4 cirrhosis of the liver and eventually liver cancer despite never drinking alcohol. So this is not related to alcohol use. Terry's Mexican American heritage and an advocate highlighting disparities in Hispanic Latino communities where genetic factors like the PNPLA 3 variant increased risk of serious complications from fatty liver.

Yet screening and education unfortunately lag. She's a national speaker and panelist, for example, the Fatty Liver Alliance in Houston, and she's had meetings with lawmakers in Washington, DC focusing on early detection, self advocacy, and preventing others from facing a liver transplant. She's been featured on other podcasts such as Surfing the Mash Tsunami. We'll talk about MASH and the Pitchable Story, sharing her empowering message. Fatty liver disease is no longer a silent, inevitable path thanks to new options like a new drug, Resdiffra, which we'll talk about with Doctor Kumar.

Our other guest is Doctor Sonal Kumar. She's board certified in internal medicine and gastroenterology and hepatology, which she's a liver specialist and also specializes in obesity medicine. She's an assistant professor of medicine and director of the Clinical Hepatology Center at Weill Cornell Medicine here in New York City. She's a clinical expert in fatty liver disease, viral hepatitis, cirrhosis, autoimmune liver conditions and more, and she treats patients daily and performs endoscopy procedures.

Related to that, she's involved in clinical trials for Resdiffra, which is the drug we'll talk about some more and serves as a consultant and speaker for Madrigal Pharmaceuticals that created Resdiffra and other companies that are advancing other therapies for fatty liver. She's passionate about non invasive screening such as blood tests and ultrasound tests for at risk patients with obesity, diabetes, high cholesterol or metabolic syndrome. So I'd like to thank both of you for taking time from your busy days to appear in the Doctor podcast program.

We really appreciate it. Thank you. Yes, thank you for having me. All right, so Terry, I'd like to start with you. Can you walk us through your journey? When and how were you first diagnosed with fatty liver disease? What were you told initially about it? And how did it silently progress to cirrhosis, liver failure, liver cancer without any alcohol involvement? Can you tell us what happened? Oh my goodness. So in 1998, I gave blood. American Red Cross is, is going to do my duty. And I got this little postcard in the mail and it said, oh, by the way is thank you for your donation.

However, your liver enzymes are high and you need to get a hold of your doctor. And I went whoa. So I called up my PCP and I said, they say I need some more tests. And so he did some more tests and sent me to a liver specialist. Liver specialist did a series of tests and came back as there was some other situations going on. But he came back and he said, Terry, he says, here's the deal. He says you have a fatty liver, He says, but don't worry about it. He says it is a common thing and everybody around us has them.

And so it's not a big deal. And so for 18 years, I didn't worry about it. That was in 1998, 2016, I started having some problems, pancreatitis, I was having some gallbladder situations. And finally in July of 2017 went into the emergency room, they found a stone in my gallbladder. I said OK, that's it. That's what's causing all the pain in my upper right quadrant. And see, that wasn't the only little symptom that was happening is that was not only was there the pain, but I was was tired all the time.

I couldn't catch my breath, I mean, as I was exhausted. And so they said, Ma, it's just your age. I love when they say that. And so I said, well, I say, you know what? I said, I want the gallbladder out. You know, just as there's a stone, if that's what's causing the problem, then let's go ahead and get rid of it. My surgeon went in. We scheduled the surgery for the beginning of August of 2017 and he comes in and he says, Terry, he says, he says the surgery went wonderfully. He says, however, now in looking at language, anytime somebody says however or but it negates all the good before it.

And so I said, OK, now what he said, well, your liver didn't look quite right and it was very nodular. He didn't use the C word either C word. And immediately I can tell you is my, my mind went to the other C which was cancer. And so I told him, I said I don't care what it is. He's it's I took some, some biopsies and I sent them off to the lab and, and to, to get them looked at. And I said, OK. I said do not just call, have your, your assistant call me and come in for an appointment. I said call me and give me the results.

I said I need to know. Five days later he gives me a call. He says, well, we have more information on what's going on. I said, OK, great. I said, what is it? He said, well, he says, first of all, he says you have stage 4 liver disease, which is called cirrhosis. And I went, wait, what? As I said, how do I have cirrhosis when I don't drink? What is the deal? He says what's caused by something called Nash and at that time in 2017, it was called Nash Non alcoholic steal the hepatitis. And I said, I looked at him and I said, So what exactly is that?

And he and he said, actually, he says, I don't know. He said, but let's the two of us go ahead and do some research and we'll figure it out and you're going to be OK. And I would love to be able to say that I had the surgery and we did the research and it was, it was quite fine, but it wasn't because within, within 7 to 10 days after surgery, I started filling up with fluid and, and I didn't catch it all of a sudden, I just noticed I was uncomfortable. And finally one day as I got on the scale and I had gained 40 lbs forty.

Wow. And you know, so that just in a matter of days, I called my PCP, he sent me in for a bunch of test and I noticed I was wet. My my shirt was was was extremely wet. And what had happened is that one of the incisions from the gallbladder surgery had opened up and I was leaking. So the fluid that I had within me was ascites. I had filled up and that leak would drained out two to three liters a day for two weeks. And unfortunately it was also during the time that Hurricane Harvey was was coming down and hitting Houston.

So there's a lot going on in the city, a lot going on in my own life. And so that's what started the whole process. So I went from unknown compensated cirrhosis to decompensated cirrhosis pretty much overnight. And when did you find out about the liver cancer diagnosis? That I learned about. So I had gone in for my first scan in November of of of 2017. I was diagnosed in August 2017, went in for my first scan and in November and it was clear. Went in for my next scan in May and by that time is through the research and stuff is I read my radiology report for my CT scan.

Of course they did a triple phase and there was a tumor and so on that I I found out on Mother's Day. Don't ever read your your reports on Mother's Day. Not a good day to find stuff. And so on Monday as I called my hepatologist and talked to his assistant and said I need you to put this my file on his desk.

I know that the tumor board meets on Wednesday. Can you make sure that it's in front of the tumor board first thing? So you eventually needed a liver transplant? Right, I did, but that was not after another two tumors for treatment. So I had two ablations AI had a taste and a tear. So why 90 and and then I qualified for the for the the transplant. So it wasn't so just having cirrhosis, just having HCC, hepatocellular carcinoma is not, doesn't qualify you for a transplant. You have to be ill enough.

And for me, it was my the tumor, the last tumor actually is what qualified for me. I was over 2cm is what how big it was, which is where it needs to be for me to be qualified is it was immediately put on but it was another almost two years before I I received the call. So it takes a while to get a liver a donor. Most definitely and. You're lucky you got one in in time. Save your life. Definitely, especially during the time that with COVID and everything, there was a lot of stuff that happened. There was a lot of stops in place for protection.

And so that I had the the transplant in May of 2022 is actually as a miracle because it was right at the the edge of when everything was opening back up. That's some story. So you went for about 20 years with this fatty liver condition which progressed to all the problems that you had, but. Definitely. You're, you're doing pretty well now. So that's very, very fortunate. Now, Doctor Kumar, for listeners who might be hearing this for the first time, What is fatty liver disease and how common is it these days?

Yeah. So fatty liver disease is when you have excess fat in the liver. So some degree of fat in the liver is normal, but it really should be less than about 5%. And when you have more than that, that's considered fatty liver disease. And there are two main reasons why you can get fat in the liver. One is from alcohol, and that's probably what a lot of listeners or a lot of people associate, you know, any liver disease with. And as we heard from Terry, you know, you don't necessarily have to be a drinker to have have liver disease or even have fatty liver disease.

So alcohol is one way to get it. But then there's also a condition called metabolic dysfunction associated to theotic liver disease or mass old. And this was what was formerly known as non alcoholic fatty liver disease, what Terry was talking about just now. And a couple of years ago it changed from non alcoholic fatty liver disease to mass old or metabolic dysfunction associated steatotic liver disease to really reflect the metabolic aspect of this. So just like you get fat anywhere else in the body, you can get fat in the liver.

And the fat in the liver, when you get it from metabolic reasons is very closely related to other metabolic processes with obesity, dyslipidemia or high cholesterol and diabetes probably being the three most common condition, conditions that we see coexisting with with mass old. And it's become very common, just like obesity is rising, just like type 2 diabetes is rising. We also see the numbers of mass old rising in, in the world, not only in the United States, but worldwide. And now it's estimated to affect about 30% of the population.

So almost one in three people will will have mass old. Is that in the USA or worldwide? That's about worldwide. The estimates in the US are about 30%, but it's it's about the same worldwide. Actually, it's not a disease limited to the United States. Well, that's, that's interesting. I didn't know was that common. Now you mentioned 5% fat in the liver is is kind of within the normal range. How is this diagnosed? How do you know that you have more than 5% and how do you know that you have MAMASLD or or Nash as you referred to it earlier?

Yeah. So that that's the, that's the tricky part because especially in early stages, so Massl does very much a disease spectrum. So, you know, not everybody who has mass old is, is necessarily going to need a liver transplant. But when we talk about MASH or Nash, what it what it was formerly known as, that's metabolic dysfunction associated steatoid hepatitis. So if I were to do a liver biopsy, I'm not saying that we do liver biopsies and everyone, but if I were to do a liver biopsy, not only would I see that excess fat, but I would also see inflammation in the liver.

And that's really thought to be the progressive form of the disease. And that's what you know, you get fat in the liver, then the fat leads to inflammation or the mash. And once you get mash, you can develop fibrosis. And we really stage fibrosis anywhere from zero to 4 zero, meaning no fibrosis, no long term damage. And stage 4 being cirrhosis. And then once you get to cirrhosis, that's when we worry about the complications like Terry experienced have, you know, losing liver function, the risk of getting liver cancer, etcetera.

Now, the the good and the bad of the liver is that in those early stages especially, and even in cirrhosis, it can be completely asymptomatic. And so a lot of people do not get diagnosed until they have cirrhosis. And this is exactly what what happened to Terry. OK, You know, maybe you say you have elevated liver enzymes, you attribute it, oh, you know, you have excess weight, whatever it may be, but it doesn't, you know, it doesn't have very specific symptoms. So it's really hard to to identify.

And so now we've really shifted to looking at other risk factors in patients to screen people for mass old. So if you have obesity, if you have type 2 diabetes, if you have high cholesterol, you're at risk for also having mass old. And so that's when we would screen patients for that, even if their liver tests are normal. Right. But how do you screen for that? What tests do you do before you say, oh, you need a liver biopsy? How? What makes you suspicious that someone needs a liver biopsy? So the good thing is that now there's been a lot of increased awareness for for the disease.

I think it was a very much a different story back in 1998, but we've come a long way since then in terms of detection. And so now there are a lot of our medical societies have published guidelines on how we should be screening people for, you know, progressive mass, old or mash and especially mashed with fibrosis. So you know, for, for providers out there, they're really easy, sort of clinical calculators are using blood work that we normally check in our clinical practice and you can compute these risk scores.

And a lot of our, you know, our electronic health record has an automatic calculator with embedded. So it becomes really easy and that's how you try to identify who's at highest, highest risk or who needs further evaluation. Right. So if someone has an elevated A1C, let's say their A1C is over 7.0, they have diabetes, they have a high cholesterol, they have high triglycerides. Is is that something that triggers a reason to do a biopsy or do you need other positive factors to go to the biopsy? So we don't typically do biopsies anymore because we've really moved away from needing a biopsy to more non invasive tests.

So if someone comes into my practice and they have these risk factors, it does not matter what your liver tests are or it doesn't matter what you know, if you had a sonogram, it doesn't matter what your sonogram or ultrasound looks like. We would screen you using these calculators. The one that we use, you know, the first line screening is called a Fib 4 score. And you would get this Fib 4 score calculated. And depending on that cut off, that helps identify who needs further testing. Because if it's low, OK, you're not at high, high risk for having scarring or fibrosis in the liver, but it's high.

If it's high, then that helps identify people who need further testing. And when we talk about further testing, it's not necessarily a liver biopsy. Now, a liver biopsy is still a tool in our toolbox, but we've really moved away from doing that, especially when you're just trying to identify how much liver damage there is. We have ultrasound elastography, transient elastography, which are ultrasound based technologies to assess for scarring or fibrosis in the liver. You can do some blood based markers like that, what's called the ELF score.

Some Mris are capable of assessing how much scarring or fibrosis you have in the liver. So the first step is to recognize that someone has risk factors. The next step is, you know, probably to do that Fib 4 calculator, calculate the Fib 4 if they're considered higher risk, you know, according to the cut offs. Then we move on to using some sort of imaging based or blood based technology to risk stratify our patients. And the goal is really to identify who may have fibrosis in the liver because those are the patients who we really need to intervene upon, whether it be for for screening for liver cancer because they have cirrhosis or even intervening in terms of pharmacotherapy.

And those are the patients we need to be most aggressive. Right. So if a patient has, let's say, diabetes and obesity, should they ask their doctor for the Fit 4 test? Yeah, absolutely. I think it's 100% warranted to say, hey doc, what's my Fib 4 score? Because if it's elevated, I may need more testing and doctors. Say, how do you know about Fit Four and they'll say I I watch Doctor podcasts. Yes. Absolutely. Well, that's that's great to know. That's a non invasive test right? Yeah, absolutely. Awesome.

And so is ultrasound and Mris and those other tests are all non invasive ways to to find out. That's great. So Terry, as a Mexican American woman, what role did cultural genetic factors play in your experience and why do you feel Hispanic Latino communities face higher risks for the complications associated with fatty liver? Unfortunately, within within the Hispanic population, there's a lot of genetic factors within that. I know that not only is the PNPLP 3 one of the genes, there are some other ones that have been identified add in lifestyle.

So, so there's a combination of different things that happen within, within, within my culture.

I know for me is that is you add the standard American diet, a very sad diet, along with genetic factors and you've got a horrible mixture. Also within the Hispanic population are higher incidence of diabetes, of high blood pressure, of heart disease. And so when you Add all of those risk factors in is you're looking at a large part of the population being affected, right? Now Doctor Kumar Mash or the the fatty liver disease is now a leading cause of liver transplants in women. I understand from my research.

And the third leading cause of cancer? Death in women, is that correct? Yeah, absolutely. It's, you know, it's, it's estimated soon to be the number one reason for liver transplant. It just falls behind alcohol all for all comers, but it's the number one reason for liver transplant in women. It's becoming more and more common. So that fit for test is really important and, and should be done. So Terry, now that you've gone through all this and you're an expert in this, what advice do you have for newly diagnosed fatty liver patients on advocating for themselves and and pushing for specialist care instead of being told, oh, don't worry about it.

We'll, you know, we'll just keep following it. One of my, one of my, one of the doctors I came across which was in the ER actually, is it she, I think really her advice helped save my life. And the advice that she she gave me was Terry, if you're going, you're going, you have a chronic illness, you're going to be in and out of the ER, you're going to need a lot of treatment. Learn the language, learn how to pronounce the the name of the disorder, learn how to identify the symptoms. Make sure that your caregiver understands those things too, that you all are learning the language of it together.

And don't ever be afraid to ask questions. The other aspect of this was I started picking my team. And the reason why I say that is because this is my body. I only have this is it. And so as a person who's in charge of my body, I'm the CEO of this body is I get to help pick the people who are going to be part of the team that are going to keep me safe. And, and so the, the team of doctors, of nurses, of technicians who have been a part of my life since 2017 are an amazing group of people who many of them, as I call dear friends because we've been through so much together.

And so it's, it's not only learn the language, but don't be afraid to speak for yourself. Don't be afraid to ask the questions, to write down the questions that you want and wait for the answers. Doctors do want to answer. And, and a lot of times they'll say, do you have any questions? And as patients, we'll sit there and go, Oh no. So they, they do want to hear your questions and make sure that you understand the seriousness of it. The other thing is to listen to the advice that you're given is it's not just somebody saying you need to lose 10 to 15% of your your weight just because they want to say that, but because it is a part of keeping you healthy.

And then the last thing I would say is don't, don't freak out, don't get, don't give up. It is so important to stay focused and move forward. And, and there is life with liver disease. There really is, right? And if you hear, oh, don't worry about it, move on to a different doctor and different healthcare providers, right? Most definitely. And, and the, the sad thing is, is that there are still doctors saying that. They're still doctors saying, oh, it's just fatty liver disease, don't worry about it.

My own son was in the emergency room and heard that he went in for gastric upset, turned out to be an ulcer. And the doctor said, oh, by the way, is you have fatty liver, but don't worry about it. I have it too. It's not a big deal. And my son looks at me and goes, oh, he said the wrong thing, right? And I, I kind of went, I said, well, I said, you know, it's kind of interesting that you mentioned that. I said that. I said, you see, is I had fatty liver too. And he goes, see, and he, he points to my son.

I said yeah, it was so bad that I needed a liver transplant. Yeah. Now, Doctor Kumar, prior to 2024, we didn't really have any medications to treat. This was basically just lifestyle changes, losing weight, controlling diabetes, reducing cholesterol. So there's a huge unmet need for medication to treat this condition, right? Absolutely. I mean, there have been decades of work that have been, you know, that have gone into trying to develop medication to treat fatty liver disease and the hallmark and it's still the hallmark of what we recommend to our patients or lifestyle modifications.

You know, we can't forget about that. Even as pharmacotherapy, even though even as medications develop, we want to make sure that we, we don't forget about those foundations. And in general, we do tell patients, you know, we recommend a Mediterranean based diet, we recommend that you try to lose weight. And we know that if you can lose 10% of your body weight, you have improvement in the scarring, have improvement in the inflammation and the fat in the liver. And we have a lot of data that supports that.

And we can't forget about that because that's still the foundation and those are still modifiable risk factors. So even as drug development advances exponentially, we have to remember that as providers and as patients that that's still an important part of our treatment. Right. So now tell us about this new drug or relatively new drug, Resdiffra from Madrigal Pharmaceuticals, which I believe is the first FDA approved drug for treating this condition. Can you tell us about that and how you were involved in that?

Yes, absolutely. This is such an exciting time. So Rezdifra Rezmedaron was approved in March of 2024 as the first medication to treat fatty liver disease. And Rezmedaron is a thyroid hormone receptor beta agonist, meaning that it's stimulus relates thyroid hormone receptor beta. And people don't really associate thyroid hormone with liver disease usually. And even in the beginning when this drug or these trials were first starting was like, I don't really know about this, but there are two types of thyroid hormone and there's thyroid hormone alpha, which is what we think of when we think about thyroid hormone.

And then there's thyroid hormone beta, which is almost exclusively found in the in the liver. And what studies have shown is that patients with progressive liver disease have a relative hypothyroidism, meaning they don't have enough thyroid hormone beta in the liver. And So what this drug does it it actually stimulates that and it helps with fat metabolism. So it helps reduce the fat in the liver. It directly targets fatty liver disease. It helps reduce the fat in the liver. It helps reduce the inflammatory pathway.

So you get reduction in inflammation and you get a reduction in the fibrosis or scarring in the liver. And you know, this is such an important point. You know, when people think about scar tissue, they think it's more permanent, but it really doesn't become permanent until you get to cirrhosis. And so you can still still intervene in patients who have fibrosis or scarring in the liver. And that's exactly what Resmedaron is currently FDA approved for. So for patients with stage two or three fibrosis, it was shown to reduce the fat in the liver, reduce the inflammation and reduce the scarring.

Well does it also work in alcohol related liver disease or only the non alcohol variety? So it hasn't officially been studied in alcohol related liver disease and so right now it's only for for patients with with mass old and mash. Now you were I think involved in the clinical trials of this drug and you were monitoring it. What every drug has side effects usually what what side effects does this drug have or is Diffra? Can you tell us about that? Yeah, yeah, I have a lot of experience with Res Diffra because we were part of the clinical trial.

We had a lot of patients that were enrolled in the trial and then subsequent to approval we've been using the the medication as well. And you know, I think it's A1 pill once a day medication, it's pretty well tolerated. And you know, both in the clinical trials and in the in real world, some people do have some GI side effects in the beginning. So I will notice that some patients will report some abdominal discomfort, some diarrhea when they start the medication. But the good thing is that it doesn't last very long.

And So what I usually tell patients is let's get get you through it. It's only a couple of weeks. Usually it resolves after a couple of weeks. We can use over the counter medications to get you through it and once you get over sort of that hump, I really haven't had any major complaints from patients about it. So very well tolerated. Yeah, it's, I'm an ophthalmologist, so I don't deal with liver disease, but I take a medical history from my patients and many of them tell me they have fatty liver disease, but they're not being treated.

So I'm going to make sure I ask them if they're being evaluated for this. Now is is the indication to use res differ? Does it require a liver biopsy to approve this? Or is it sufficient to do all the other non invasive tests to make the diagnosis before you start res differ? That's such an important point. So in the clinical trials in order to show efficacy right now the FDA still requires us to do liver biopsies for clinical trials. And that's because they want to make sure that what we're looking at it, you know what we're concluding from these trials is the gold standard and is, is accurate.

However, with approval, you are not required to have a liver biopsy to determine your stage of fibrosis. These non invasive tests, the transient elastography, the Mr. elastography and even that ELF score, those are adequate to determine stage of fibrosis and get patients on Resdifra if appropriate. That's that's great to know. Now Terry, have you used RES differ or do you know people who are who are using it who have fatty liver disease? I do know quite a bit of people who are using RES differ for me is for any of the medications that I put it this way, by the time I my MASH was found, I was too far advanced to be able to qualify for any clinical trials or any medications.

So part of what I do as a patient advocate is to make sure that the word is getting out there that populations are being educated and that the knowledge and understanding increases substantially. So I got to for the celebration is, yes, there was a celebration when it was approved is I got to be one of the speakers there on for that weekend and was very happy to be there. So I am a champion for the medications that are coming up because it's going to save lives. It is saving lives and we haven't even seen the full impact.

Yet, right. That's great. Now, doctor Kumar let's you talked about lifestyle as the first thing to do. You need to lose weight, you need to exercise, you need to control diabetes and so on. What if a patient just can't do those and and many patients have difficulty with the lifestyle changes? At what point do you start RES Differ Or would you first start on one of the GLP one drugs such as Wegovi or the other drugs for diabetes or weight loss? Or do you sometimes use Ozempic or Wegovi or Munjaro in combination with RES Differ for treating patients who have advanced disease?

Yeah. I think, you know, we have to realize that this is a metabolic disease and it's a chronic disease and it is not a one-size-fits-all. Just like people who have high blood pressure and one person would respond to a certain medication and versus another. That's the same thing with with fatty liver disease or with MASLED. And so you really have to take the whole clinical picture and the whole patient into account. We go V has also been FDA approved now at the end of last year for patients with MASH and stage 2 to 3 fibrosis, so similar to to Rezdefra.

And so now we have 2 tools in our toolbox when it comes to medication. Then we really individualize the therapy. I will say that a lot of the patients by the time they come to me because they already they have diabetes, they have obesity, a lot of them already are on the GLP ones once their liver disease gets diagnosed. And so in those situations especially I will use combination therapy. If you still have fibrosis despite being on one of the GLP ones, then you need something else. We really don't want to get to the point of cirrhosis where it becomes irreversible and you know, it is not an either or drug.

And again, it's not a one-size-fits-all. And so sometimes in patients and a lot of patients who, you know, you know, may not be significantly overweight where we feel like genetics is a big factor or their diabetes is very adequately controlled on whatever medication, you know, then I would start risk meter on or Rezifra, you know, and like I said, a lot of patients are always already on the GOP 1. So we use combination therapy, we use single, you know, single drug, but it really it depends on the patient.

So there's no sort of blanket algorithm that I that I use for my patients. Right. So you customize it for every patient. Absolutely. Right now, I understand World Liver Day is coming up on April 19th, which focuses on habits for liver health. What's your outlook for the next decade for fatty liver disease, Doctor Kumar and you? I think you mentioned there are other drugs in clinical trials for this. Yeah, I think the future is very bright for us as providers and more importantly for for patients.

It's, you know, I been part of clinical trials for over over a decade and I've watched medication after medication fail. But now I think we've had a turning of the tide and now we've had we have two medications that are approved and I think this is just the beginning. And there are a lot of other medications that are in late stage development in their clinical trials. And I think and then next 5 to 10 years, the landscape is going to be completely, completely different than what we even see today.

And it's really, really an exciting time, most importantly for the patients. Yeah, that's awesome. Great news. Now, Terry, any final thoughts, Any calls to action for viewers watching this program to get screened or advocate? What advice do you have for the public out there? A couple of things, first of all is it's not just an adult disease, so it also effects children. And so if a mom and dad end up or have it is as it would not be a bad thing to have children screened as well. So just it, it can be a family thing, unfortunately.

Yeah, you mentioned there are genes that increase your risk for this. So definitely and because of the way that our society is unfortunately is obesity effects children as well as diabetes does. And so all the things that affect adults also affect children. The other thing is just to be aware is to hope that it don't go with hope that I hope this isn't going to happen with me, but to be is proactive and go ahead and get tested. That is the number one thing is it doesn't hurt to be able to say, hey, can you run my liver panel?

And with that is, hey, what is my fib for? OK, you don't know what the fib for is. Let me pull up a calculator is as a patient, I can pull up a fib for calculator. So there's a lot of things. And so people might say, no, you know, this is not a big deal. You know that my doctor said don't worry about it. Having gone through cirrhosis and all of the symptoms that go with cirrhosis, it is a big deal. It is a horribly big deal. So education is really key here, very important to know, and I want to thank both of you for educating me and the public about this very important topic that I think is is ignored.

We need to educate the public as well as doctors about this condition and everybody will be much healthier. So I want to thank you both for taking time out of your busy days to join us on doctor podcast program to share your experiences and knowledge with us. Thank you. Thank you so much for having us. Thank you.

In this episode