Ep 4: Unlocking the Fatty Liver Mistry

The Whole Patient, The Whole Journey: Dr. Mistry Opens Up

[00:00:07] Neeraj Mistry, MD: Welcome back to episode four of Unlocking the Fatty Liver Mystery. I'm Dr. Neeraj Mystery, and I'm the Chief Medical Officer of the Fatty Liver Foundation. This is going to be a special episode because we are actually going to be demystifying Dr. Mistry. I’m going to be in the hot seat and you're going to learn all about my journey coming into fatty liver disease.

I have been really fortunate to ride shotgun on these episodes with our producer extraordinaire, Sara, who's going to be joining us in this episode. And she's going to be asking a few questions, both out of her own curiosity as well as those questions that have been coming in from some of our audience.

So, Sara, over to you.

[00:00:50] Sara Fagerlie, PhD, CHCP: Well, thank you so much for speaking with me today and for answering the questions that our viewers want to hear. I want you to go back a little bit just to start off, tell us a little bit about you and your background. 

[00:01:04] Neeraj Mistry, MD: So, I actually come from South Africa. I was born in South Africa, and I am third generation South African of Indian origin. So, my forefathers came from India, and there's a whole colonial history on how we ended up in South Africa. South Africa's a very interesting country where we have. the best of Western Europe and the worst of deepest, dark, darkest Africa added, 10-mile juxtaposition. And how that manifests in a health perspective is that we have a double burden of disease, which is infectious diseases, pestilence and famine, as it used to be called, as well as nutritional deficiencies. And then on the other hand, we also have lifestyle diseases. Which are related to western diets and sedentary lifestyles with the increasing in diabetes, metabolic syndrome, hypertension, et cetera. So, we face a dual burden of disease, which is what sort of got me really interested in both these areas.

First, addressing infectious diseases and then addressing non-communicable or lifestyle diseases. So, my journey was quite interesting because I practiced in both. Urban environments like Johannesburg, which for all intense is a Pan-African metropolis, as well as working in very rural areas where a few colleagues and I had these four by fours and we drive like 300 miles a day stopping in different rural areas. Seeing patients. And so, we saw a really, really wide range of diseases.

As I sort of practiced, what I needed to see is what is happening in the big wide world, when it came to disease at a clinical level. and that took me to the, uh, United Kingdom. I was based out of London, and I worked in the public and the private sector there. But something interesting happened, which was I needed to understand, well, what was the bigger picture that influenced my clinical practice? And that's when I went to the London School of Economics and did an economics degree because that influences all of policy, how we allocate resources to which diseases, et cetera. And that then led me to working in international development and global health, which brought me to the United States. And when you work in health, you have to know what's happening in the pharmaceutical industry. So that took me to Merck and Co Inc. in the United States. and, and then I was very interested in working in infectious diseases, HIV, TB, malaria. Those were the big global health and development challenges that we faced.

But at some point, I pivoted from those diseases and neglected tropical infections. To non-communicable diseases, or lifestyle diseases, and here's what has been happening. Because when we look at global health, we are actually doing quite well. When you look at the key indicators, life expectancy, maternal mortality and childhood mortality. We've been improving steadily over the past century when it comes to all these indicators. And so, what happens when we tackle infectious diseases is that people live longer. Usually people would dive tuberculosis, HIV, malaria, et cetera, in their teens, in their early twenties, in their thirties, and now because we found solutions to that, people are living longer. And when they live longer, they start getting those lifestyle diseases like diabetes. They get overweight, sedentary lifestyles, especially with the technology boom. And we start seeing the onset of these non-communicable diseases.

And I think it's worth dividing it into two categories. One is the lifestyle or metabolic diseases that we are facing, of which fatty liver disease is part of that. And the other are the cancers. And when you think about, well, cells divide and something might go wrong in the division and cancer results, the longer people live, the more cell divisions and invariably with the external influences or carcinogens, they could develop cancer. So that's broadly how we look at things.

So, public health physician having worked in the public sector, in the private sector, in the global north and the global south on a wide range of diseases from infectious diseases to these non-communicable diseases. And what's also interesting is not just at a clinical level, but right to a global policy level. That's offered me a very interesting perspective on global health and international development.

[00:05:41] Sara Fagerlie, PhD, CHCP: That's quite a story, quite an impressive history there. So, how did you end up at the Fatty Liver Foundation?

[00:05:49] Neeraj Mistry, MD: With that journey, into, working on lifestyle and metabolic diseases, this is where I, I felt. Wow. There's this convergence of all these metabolic diseases, which we've talked about at length, diabetes, hypertension, high cholesterol, metabolic syndrome, which is linked to being overweight and obesity. I. But the interesting thing when we talk about all those comorbidities is that in society, especially advanced economies like the United States and past of Western Europe, diseases have become normalized. Right. And I've, I can't tell you how many times I've heard. Oh, doctor, I don't have diabetes yet. And there was almost like this expectation that it, people were on this trajectory. My uncles had it, my cousins had it, so I'm going to get it. And we are all quite big and heavy in our family. and so that normalization meant that we had to find another way to instill the sense of urgency, the sense of self responsibility in people and, and when I looked at the landscape, I felt that fatty liver disease was, was a really important entry point for people to reexamine the comorbidities and those factors affecting their life and their wellbeing. You know what was also interesting in the Fatty Liver Foundation was we conducted, the Sun study, which was the screening of undiagnosed NASH and NAFLD among patients, and we went to these, what we called enriched communities, people that were at high risk of disease, and we screen them. And it was interesting cause they didn't know they had the disease. We often talk about it being a silent disease, but the moment they saw the printout of their result, which showed a normal curve, and then their curve of their liver fat and their liver stiffness, they all of a sudden had this eureka moment. And as our founder likes to say, it's a teachable moment where they see this paper in front of them and they're like. Oh, I have to do something about it is very different from someone being told, oh, your blood sugar is high. You possibly have early diabetes or pre-diabetic.

And so, this was a really, really important point, not just. In terms of diagnosis, but in terms of, affecting the lifestyle of the patient by making them look for health seeking behavior, as well as them taking responsibility for their lifestyles. And so that's what led me to join the Fatty Liver Foundation.

[00:08:27] Sara Fagerlie, PhD, CHCP: So now you're Chief Medical Officer of the Fatty Liver Foundation. So, tell me a little bit, because now you're a health provider, but working in a patient advocacy group, tell me a little bit about how that's different or unusual, how you're able to embrace things from a patient perspective.

[00:08:45] Neeraj Mistry, MD: So, it's been quite interesting. I have to say also quite frustrating as a physician and, and you would see a patient and you'd identify their risk factors and you'd say, well, you have to lose weight. You have to stop drinking and you have to stop smoking. And six months down the line, the patient comes back to your office and lo and behold, they're still smoking, they're still drinking, and they haven't lost any weight. are like, well, why haven't you done this? and we approach this from such a rational perspective where it's like, well. Here's all the data and this is what you need to do. And we impart this information to patients, and we say, well, they should be following this, and why aren't they following this?

And these patients are noncompliant and do not a adhere to the advice we're giving. But all of a sudden when you flip the script, and you start putting yourself in the patient's shoes and you look at what their lifestyle is like. What their stressors are like, what their risk factors are, like the fact that they don't have a green grocer in close proximity, the fact that they don't have the support mechanism to deal with addiction of alcohol use or smoking cigarettes.

And we don't do that. We are never going to find those sweet spots of impact and change in behavior. And so, I needed to understand it from a patient point of view. Just a little anecdote, my wife feels that I am too much of an empath, putting myself in other people's shoes. feel that if we understand it from the patient point of view as well as the provider point of view, that sweet spot is an intersection where we have greatest impact.

And that's what led me to a patient advocacy organization to advocate for that situational context in which patients live. Rather than the doctor's room where they visit. and it is in that understanding that we can affect the greatest change. And so, becoming a patient advocate was actually a coming of age moment for me as a physician to actually then see it from the patient perspective.

[00:10:49] Sara Fagerlie, PhD, CHCP: we talk about multidisciplinary teams. What are multidisciplinary teams? Why are they important, especially when dealing with these lifestyle diseases?

[00:10:57] Neeraj Mistry, MD: you know, this goes back to our education system. We have our education neatly uh, packaged in these silos. Here's science and here's the arts, and here's humanities, and here's engineering and biology, et cetera. And life doesn't actually operate that way. It's, it's this wonderful matrix and this muckety muck messiness, right?

And that's the reality. Interestingly, there's some elementary schools that are saying we are not going to teach by subjects anymore. We're going to teach by themes. And so, where they, they would take on a theme like the oceans. And in the oceans, there's marine biology and there's ocean currents, which is geography, and there's, changing water temperatures, et cetera. And so, they learn about things in a very holistic way. And what we often do is we deal with our patients as subjects in science or scientific subjects that we need to study and analyze, to which we then apply a scientific intervention, we don't, I. Consider the patient in their entirety. you know, when I taught at Georgetown University in Washington, DC in the School of International Health, Georgetown having the Jesu tradition has a wonderful motto, which is cura personalis treating the whole person.

And that's understanding the person as a scientific entity or being to whom we analyze. Understand and then do these interventions. But they live in a social context. They live in an environmental context. They have a heart and a mind, not just physiology. And how do we address all of that? And there's a wonderful behavioral eco economist who, who, who won the Nobel Prize in economics, Daniel Kahneman.

And he wrote this book called Thinking Fast and Thinking Slow. And so, the likes of us as scientifically trained people think slowly. We analyze, we look at the data, we formulate a hypothesis, we recommend a course of action, most of the population are fast thinkers. It's gut, it's instinctive. It's, it's a behavior type of mechanism that is not rational. And when you actually break our thought process down. Well, we might not be totally rational ourselves. but it is understanding that mindset that's really important. I'll give you one example from my days in infectious diseases, we used to ask patients to wash their hands to prevent germ transmission. as a doctor wearing a white coat and I walked in, I'd say, wash your hands because we need to kill those germs. Only a few people wash their hands. in a priest who said, cleanliness is next to godliness. And lo and behold, everyone washed their hands. I. Now for me as a public health physician, I am agnostic as to why they wash their hands. I just needed the outcome of hands being washed. And I think that's the interesting point that we at now in health and medicine, where we have to think about things in a much more comprehensive way. And the way we do that is with multidisciplinary teams. Initially, different disciplines within the health domain. So, you would have a hepatologist, a gastroenterologist, primary care physician, a dietician who understands the context in which someone eats, not just what foods are nutritious. A physiotherapist, an occupational therapist. We are now starting to see music therapists, aroma therapist, massage therapist. All becoming part of the team. Stress is one of the biggest drivers of people eating people not having healthy lifestyles, not getting enough sleep. And if we can introduce them to things like yoga and meditation as part of that multidisciplinary team, I. We are taking care of the entire individual and that's going to yield much better outcomes.

And, and while it sounds really complex, it's actually becoming much better. We are seeing the emergences of emergence of many multidisciplinary centers across the United States where they're taking care of the whole patient, especially when it comes to these lifestyle diseases.

[00:15:07] Sara Fagerlie, PhD, CHCP: Can you gimme an. Example of an institution that you see or a place or a space where they're like doing it the way you'd like to set the tone. Set an example.

[00:15:18] Neeraj Mistry, MD: So, there's many, university affiliated hospital setting. And, for example, Mount Sinai in New York City, they are tackling this really, really well. And it was interesting talking to a colleague there who's a hepatologist where she said. In order for me to best serve my patients, what I do with them is not necessarily for me to be a hepatologist in order to do that, and I really admired her for actually taking that position because she responded to what the patient needed. than what she could provide as a hepatologist, and she had to shift a pattern. I'll give you an example of something that I did. I actually sat down with a patient and I asked them to break down their day on an Excel sheet by the half hour when I said, oh, you need to watch what you eat when you eat it, make sure you're getting enough rest.

Make sure you're walking 20 minutes to 40 minutes a day. They said, all right. try that. And when they came back in three months’ time, they hadn't done all of that because they couldn't program it into their lifestyle. And we sat literally with an Excel sheet by the half hour and inserted when their interventions needed to be.and I made sure I created check boxes that they could do. 'cause there's a good dopamine hit when you check something off your list. And that actually started changing things, for that patient and changing their lifestyle and their behavior. And so there's many centers now that are using, appropriately technology apps that do all of this, but I think there's something else that was very important with it, there was a human being, myself and the hepatologist at Mount Sinai that actually sat with patient and they had that engagement and interaction and there was another university now in their medical school that is mainstreaming narrative medicine, which is focusing on the bedside manner, the way the. Health providers interact with the patient because that is as much, if not more impactful in achieving a health outcome than the scientifically proven medication or therapeutic that we often prescribe or recommend.

 in the sort of really wonky, geeky public health world, we often refer to all these as the social determinants of health, or SDOH, and initially social determinants of health were clean water, sanitation, electrification, et cetera. But I think we're starting to see a shift in those social determinants of health. It's the type of work people do. It's whether they work remotely or not. The, the how sedentary they set, their lifestyle is, or their work environment is, the level of stress they face. Uh, the type of home environment they have, the relationships that they have. Both professional as well as personal and all of these determinants are, I think, shaping what the modern day contemporary social determinants of health are. So, I think we have to really be cognizant to these factors as we start thinking of health in a broader sense. When we used to look at the wellbeing of individuals, we used to think of it in a medical way and the functional unit, to provide medical care, used to be the doctor. And now when we are talking about health and wellness more broadly, the functional unit or the function is not medicine and the doctor, it is the health worker.

And the health worker can take on many, many forms from doulas to your yoga therapist, to your green grocer. Who recommends the type of food you need to eat? and so it's more like a team in the health of the individual that we are looking at.

[00:19:05] Sara Fagerlie, PhD, CHCP: so just thinking about, the state of health in our world, how would you describe it, especially with regard to morbidity and mortality, what are your thoughts there?

[00:19:15] Neeraj Mistry, MD: it's interesting because everyone wants to live longer, right? And that's, that's an important goal for us from a science point of view and medical and health point of view, as well as from a societal point of view. But what we need to pay attention to is not just mortality and extending mortality, or increasing life expectancy, but we need to look at the quality of life. And this is morbidity. And so how do we? address the wellbeing of populations by ensuring that they live for as long as they can in as healthy a state that they can. And that's addressing those lifestyle factors which we talk about. So, ensuring that they are an appropriate weight for their body frame. note, I don't say BMI because it changes by different population, but based on their frame, based on their genetics and the environment in which they live, what is the optimal weight that they need to have? How do we ensure that people are living their best life, not just in their physical form, but in their mental and emotional wellbeing?

And you know, Sara, it's interesting because the World Happiness Report just came out and the Swedes and the Danes particularly have been doing quite well on this. And, and they were, were really, telling points that came out on what makes a community or a population happy. And one of the things is rain, wind, shine, or snow, or blizzards, they are outdoors. When you look at the number of outside parks, lakes, et cetera, they spend a lot of time outdoors. So, being in a natural environment is really, really important. There were other things that really came out strong, which were, interpersonal relationships, not just within families, but in the work, extended work environment.

And it's going to be quite interesting now that we are living in and working in a remote world as well as trying to get back to the office. How do we balance those two? How do we reduce social isolation and loneliness? And how do we promote healthy relationships within families, within communities and in the work environment? There was one data point that I was looking at which said young people. know how to date anymore because a lot of their engagement is on social media and on apps that the interpersonal in, interaction and connection is something that is starting to wane. So, we need to make sure that we have the tools and technology, but how do we also get back to those sort of basis of our beings, which is making community and engaging and interacting. So, all that to say, addressing those quality of life issues is really, really important. And Sara, I hope I don't get too esoteric with this, but the two M that you mentioned. Mortality and morbidity are really important. And I've been talking in public health, about a third to our lives. So, it's morbidity, mortality and meaning. And if we find that. Greater quest, and it's not one size fits all. It's not one answer that is the meaning to life, but each person has that own subjective what gives us meaning or what gives them meaning. I think that's really, really important and it's not necessarily about. Answering the question, but more so about asking the question, are we so busy on the treadmill of life? We've got to make it, we've got to get this, we've got to get that. That we've never stopped to say. To what end? Why do I need to do this? Why do I need to live longer? Why do I need to live healthier? it's not just for me as an individual, but in the environment that I live. And so, when we think about, especially lifestyle diseases, having that reflexive question to say, well, what does this all mean? And to what? End is all of this, may be a good way for people to take stock, reexamine and, and live their best life. I love that. That is, that's a really, profound way to think about things and a new way to think about things.

[00:23:39] Neeraj Mistry, MD: Well, Sara, I was really spot on when I said you were our, our producer extraordinaire. Because you're usually behind the scenes, but having this conversation with you was lovely and you asked really probing questions, I really appreciate.

The space to talk about these issues because we don't often talk about them, especially on science driven and medically driven, webinars and podcasts. And I think this opens up the world for us to understand health in a much more holistic and comprehensive way, which is critical for us to achieve the behavior change and the health outcomes that we want to. So, I appreciate this space and looking forward to episode five where we have one of the leading hepatologists in the world who's going to talk to us about nis, and I'm not going to explain what it stands for until we get to the episode.

This transcript has been lightly edited for clarity.