 and welcome to the latest edition of Tell Health in Hawaii. It's great to see everyone again. My name is Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health, a local healthcare services provider based in Hawaii. We have a great show for you today. I'm very excited to introduce long-time friend of the show, physician, leader, researcher, author, Dr. Sanjeev Chopra. Dr. Chopra, it's a pleasure to see you. How are you today? I'm on top of the world, Vikram, waiting to be on the show. It's good to see you, as always, good to see you. To get the ball rolling, we have a lot to talk about when it comes to viral hepatitis, it's viral hepatitis month. But to start, tell us a little bit about yourself, where you're from, your current role at Harvard Medical School, and we'll go from there. So I'm a professor of medicine at Harvard Medical School. I had the privilege and honor of serving as the faculty dean for continuing education for 12 years. I now direct with a colleague of mine, the continuing medical education division for the Department of Medicine at Beth Israel Deaconess Medical Center. And I'm a Marshall Wolf distinguished clinician educator at the Brigham & Bromance Hospital. I direct CME courses around the country, around the world. And I speak on topics other than medicine as well, including leadership, happiness of living with purpose. I'm living a dream. Mark Twain once said, the two most important days in your life are the day you're born and the day you find out why. Each one of us has a singular purpose in life. I'm living that purpose. I've written a book on it. It's called the two most important days, how to find your purpose and live a happier and healthier life. So I'm privileged to travel around the world and either as a tourist or very often as an invited keynote speaker. See, in the world of gastroenterology, Dr. Chopra, you're a hepatologist. What is a hepatologist for our non-clinical audience? Well, hepatology, the hep R is beans to liver. And hepatology means the science and art of liver disease. So I became a hepatologist when I finished my gastroenterology fellowship then I did another couple of years of training in hepatology with a giant in hepatology by the name of Dr. Raymond S. Goss, one of my mentors in life. So that's what I do. I teach hepatology. I now see second and third opinions and I see that with a junior colleague of mine and then I let them do the follow up. I let them do all the billing and all the necessary procedures. Now, this month across the world is viral hepatitis month. That's a lot to unpack. Can you walk us through what viral hepatitis is and we'll go from there? Yeah, so viral hepatitis means information of the liver due to a virus. And the four, five major viruses, it's very easy. It's the alphabet soup. So hepatitis A, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus. And the ones at the extreme and A and E can lead to acute liver disease. And when the patient recovers, they recover fully, never leads to chronic liver disease, never leads to cirrhosis. They can be serious on rare occasions. Patients can be very ill from hepatitis A and from hepatitis E. Hepatitis E in particular can be very serious in pregnant women in the third trimester. If they get hepatitis C, there's a 20% mortality. I was recently asked by a physician, you know how you get these cafeteria consoles. Oh, Sanjeev, I was gonna call you. I have a patient and she's going to Mexico and what should she take for travelers, diarrhea, prophylaxis? She's pregnant. I said, how pregnant is she? She's late second trimester and I said, how long is she gonna be in Mexico? Couple of months. I said, she should not take anything for travelers, diarrhea, prophylaxis because she shouldn't go. If she goes to Mexico and gets acute hepatitis E, one in five chance of dying and we don't have a vaccine for hepatitis C. We have an amazing vaccine for hepatitis A. We have an amazing vaccine for hepatitis B. The hepatitis B vaccine is truly the first anti-cancer vaccine. Hepatitis B afflicts somewhere around 350 million people in the world. Hepatitis C inflicts about 170 million. So between these two viruses, more than half a million people in the world by these viruses. Hepatitis B virus, we have an amazing vaccine that works even in childhood. And now in the United States, every pregnant woman is tested for hepatitis B virus infection and if she's positive within 12 hours of birth, the newborn is given the first shot of the hepatitis B vaccine. And also given a special product called hepatitis B immunoglobulin. So the hepatitis B immunoglobulin confers passive immunity. The hepatitis B vaccine is then given again twice and it confers active immunity. And it markedly, markedly, markedly lowers the rate of these newborns from getting lifelong infection with chronic hepatitis B virus. Palmer Beesley did a study in Taiwan many couple of decades ago. And in Taiwan, the prevalence of chronic hepatitis B was 15%. And then with childhood universal vaccination in Taiwan, in two decades, it dropped from 15% to 1.5%. More interestingly and dramatically, childhood liver cancer mortality, death from liver cancer occurring in children due to chronic hepatitis B infection dropped by an astounding 75%. So truly the first time I cancer vaccine and we have another vaccine against cancer and that is the HPV, the human paparoma virus vaccine, which prevents cervical cancer and throat cancer, so two remarkable vaccines. Chronic hepatitis B, we can suppress with antivirals. They're called directly acting antivirals. And we use them also for hepatitis C. But we can suppress chronic hepatitis B and can lead to better outcomes, less risk of liver cancer, less need for liver transplantation. Chronic hepatitis C, we don't have a vaccine, but we can actually cure it. It's the only chronic viral infection in human being where we can use the radical term cure. And when we first started treating chronic hepatitis C, we used interferon and injection for six months and it had a 6% cure rate. Six percent. And now with directly acting antivirals, we are between 90 to 100%. And it doesn't matter if they have cirrhosis, very advanced liver disease, ocean of the liver architecture, the potential for life-threatening complications, need for liver transplant development of liver cancer, even if they have cirrhosis with chronic hepatitis C, we can cure 90 to 95%. Even if they have co-infection with HIV, even if they have cirrhosis and co-infection with HIV, we can cure. So train it. Interesting. You may not have a vaccine, but you have the cure. Yeah. And that's very interesting. Well, hepatitis B, we have a vaccine, but not a cure. But hepatitis C, we have a cure, but we don't have a vaccine. Very interesting. And the people who did the seminal work in discovering hepatitis C, Michael Autel, PhD from England, working for a small corporation, the current corporation in California, first crack the code. We used to call it non-in-non-B. It was not A, it wasn't B, it was another virus. And then he discovered it. So hepatitis C together with Harvey Yalter and Dr. Charles Rice, the three of them got the Nobel Prize. Is he all the German? How do you, you've mentioned infants, pregnant women, how do you obtain these viruses? What happens to the body to receive these different types of... Hepatitis B virus is present in crostrum, in mother's milk, saline, tears, liver, spleen, kidney, adrenal glands, lymph nodes, all over the body. And that's why it's so difficult to cure it, to eradicate. And one can get infected by sneeze drops, by saliva, by blood, dentin blood. Hepatitis C is mostly blood-borne. There is transmission from the mother to the newborn, but it's about five to 10%. So I would tell my patients before we had a cure, can I get pregnant? Can I breastfeed? Yes, you can breastfeed, you can get pregnant. And the risk of transmission is 10%. I wouldn't say that. I would say 90% chance your newborn will not get hepatitis C. So very different. That's why I think we can cure hepatitis C. It's basically in the liver, whereas hepatitis B is all over the body, and all the fruits. Now the trajectory to have a patient visit with someone like yourself, a hepatologist, how does it typically work? You'll see your OBGYN, or perhaps your primary care physician, who then directs you to a hepatologist. What's the trajectory normally? The usual story is that patients get discovered because they have elevated liver enzymes, and then the primary care physician will embark on a workout to figure out. We'll often check them again to make sure it's not a lab. Still elevated. Now let me check for hepatitis B, hepatitis C. Are you drinking alcohol? What medicines are you taking? Are you taking herbal supplements? So many causes of liver dysfunction. And then the blood test will show that they are either hepatitis C or B, and then they usually refer them to a hepatologist. And then from there you run the work-ups from there to there. Yeah, then we, you know, hepatitis C is often first diagnosed by a hepatitis C virus antibody. It's not perfect. If 70% of people who get acute adults who get acute hepatitis C go on to develop chronic hepatitis C, but 30% recover on their own. And this test for the hepatitis C antibody is durable and hangs around. So they may have recovered, but the test is positive. So now how do we distinguish between past infection and current ongoing infection? We look for the virus. So we check what's called a hepatitis C virus RNA test by polymerase chain reaction, ECR. And if that's positive, they're currently infected. And then we treat them. And we screen family members. We tell them not to share toothbrushes, razor blades, nail clippers. They can share food. That's not the way you're going to transmit hepatitis. They've been in a steady monogamous sexual relationship and the partner is negative. Unlikely, it will be translated in the future. If you look for hepatitis C virus RNA by PCR in the semen, the saliva, we don't... I see. So that's how people using intravenous drugs and sharing needles, that's a rampant way to acquire hepatitis C. Yeah. In six months, 50% acquire hepatitis C. Within just six months, six months of sharing needles. And within a year, 75%. And then 75% of them will become chronically infected. So we have to address that. We have to address this epidemic of drug addiction in our country all over the world. Another way people can get hepatitis C is through cocaine snorting. I have many patients. That's the only risk factor. No tattoos, no acupuncture, no blood transfusions, da-da-da-da. But they have a tattoo. So how does that happen? And they have cocaine snorting. And cocaine snorting, apparently, they often use a dollar bill or a hundred dollar bill and put the cocaine on it and start it through a straw and pass it around. And there's a high frequency of nosebleeds and contamination of that with blood. And now you're inhaling that. So with the growth of the drug epidemic over the past 15, 10 years, you've seen skyrocketing rates? Yeah, we've seen a resurgence. And the sad thing is that although we have a cure, many, many, many thousands of people are not being diagnosed and are not getting the cure. That's a travesty. That's a tragedy. Yeah, create more awareness. And what I tell my colleagues, physician colleagues, nurses, nurse practitioners, peers, I say we have an obligation to go to elementary and middle schools and talk to them about good health. Size, not getting overweight, not drinking alcohol in excess or not drinking it at all. If a biological parent has a history of alcohol use disorder, not using drugs, don't do tattoos. You know, be very careful about needles. Acupuncture. Yeah, so it's interesting. There's a lot that can be done on the prevention side, the education side, before they end up having to see some. Absolutely. Yeah. I have so many patients who say, Dr. Chopra, I use drugs in the ETs for six months. And I'm a good citizen now. I'm a good father. I'm a good parent. I'm going to die of cirrhosis. Am I going to need a liver transplant when I get liver cancer? And I always say to them, yesterday's history. Tomorrow's a mystery. Today's a gift. That's why we call it the... Mm-hmm. I'm going to treat you. We have a very good chance of a cure. Even when we were using peg interfrawn, a special interfrawn injection once a week together with an antiviral called ribovirin. It had a 30% cure rate. So it went from 6 to 15 to 30. And now it's 9,200. And I would have patients on whom I'd done serial liver biopsies to see if they're having progression of their liver disease. And 10 years later, 12 years later, they have early cirrhosis or significant scarring. I say, we have to treat you. But Dr. Chopra, it only works in 30%. I said, 30% means that if I treat 1,000 people, 300 will be cured. 200? It could be one of them. Dr. Marin, can I ask you a question? You know, that time we would treat for three months, test the virus level. If it hadn't budged, it's not going to work. All right. Are there any types of symptoms of liver disease around these virals? A lot of people with chronic hepatitis B and C have no symptoms. Or they have very nonspecific symptoms, a little bit of discomfort in the liver area, under the right rib cage, a little bit of fatigue, totally non-descript. Nothing that, oh, you've got hepatitis B or C. Some have with hepatitis C syndrome called mixed cryoglobulinemia. And they can develop a rash, joint problems, and numbness and tingling in the hands and feet, peripheral neuropathy. So we always ask every patient with hepatitis C, do you have numbness or tingling in your hands and feet? Do you have raised red dots on your shins? Tell me about your joints. Do they ache? The answer is yes, we check for cryoglobulins, simple blood. But those that are concerned, you know, after this type of good conversation, what are some initial steps people can do, you know, to get themselves checked or to inquire more about a lot of the types of different types of ache? I think that there is now a movement that every person should be tested once for chronic hepatitis. In Italy, the recommendation was baby boomers. And the reason was, you know, maybe they use drugs, maybe they started cocaine. So let's test every baby boomer in America for chronic hepatitis C. You know, it's a simple blood test. So every care physician can do it. The other way to get tested is to be altruistic and go to the Red Cross and to knit blood. And if you have hepatitis C or B, you're going to get a letter from them. They're positive for one of these viruses. Go see a doctor. That's the way to get tested. That's how a lot of people actually get discovered. They go to give a blood transfusion and we test every unit of donor blood for hepatitis B, hepatitis C, HIV, or the viruses. Are there certain countries that have higher rates of hepatitis, viral hepatitis that you've seen from the studies than other? Hepatitis B is very common in Asia, in China, in the Philippines, Thailand, Korea. Very, very common. And it's due to vertical transmission. So vertical transmission means from the mother to the newborn. Horizontal means from an adult to an adult. Hepatitis C at one time had the highest prevalence in Egypt. In Egypt? Well, they have a parasite called schistosomiasis. And they were going around the country treating people for schistosomiasis and not sterilizing the needle in between people. And in some villages, 50% of the population was infected. So the government got on a program and they basically eradicated hepatitis C in Egypt. It's a remarkable story. Why the higher rates are there in Asia and some of the countries you've been to? That's a good question. We don't know, but because these asymptomatic mothers have chronic hepatitis B and they're not tested during pregnancy and then the newborn isn't protected. But why they have it more to begin with? Okay. Yeah, I mean, the information you provided is always extremely helpful, you know? Explaining education on viral hepatitis, the different types that people can obtain, it's all extremely good information. We always thank you for your time. For folks who are not in tune with this, it's an extremely important information. And especially around prevention, as you mentioned, going into schools, reaching out to young ones at a early stage of their life. Not exactly. But as you said, you know, alcoholic liver disease or alcohol use liver disorder. Liver disease right now in the world is non-alcoholic fatty liver disease. It's called non-alcoholic fatty liver disease. There's a movement now to change the name to metabolic associated steatotic liver disease. Likely happened. But it's called that because under the microscope it looks like this person's drinking a lot of alcohol, but they're not drinking. They have obesity and type 2 diabetes. 1.5 billion people in the world are estimated to have non-alcoholic fatty liver disease. 1.5 billion. The most prevalent chronic liver disorder. And 10, 15% of the time it eventuates into cirrhosis and liver failure. It's now the number one indication in stage liver disease non-alcoholic fatty liver disease for liver transplantation in our country. Number one or two indication. Every academic medical set. So we need to exercise. We need to take vitamin D. We need to lose weight. I think the game changer now are these new medicines. GLP1 agonists where people are expensive. But if you can take them and get them, you can lose 30, 40, 50, 60, 80, 85 pounds in a year. And the liver disease can reverse. Hypertension disappears. Diabetes disappears. Hyconestrone disappears. Within two years, you are paying for the medicines because you don't need these medicines or you need marketing less tools. So we need to exercise. We need to get the kids off the computers and the iPhones, the laptops, and to go like we used to do when we were young. Go on the basketball court. Go for walks. I read about a family where they decided to do green time, which is meaning going for walks and going to a farm and plucking vegetables instead of digital time. And the kids preferred the green time. Part of it was they had the attention of their parents. They were all doing it together. Is there a correlation between weight loss and liver improvement or reduction in non-alcoholic state hepatitis? Yeah, yeah, absolutely. And we learned this best from bariatric surgery, gastric bypass surgery from morbid obesity. In protocol studies, surgeons would do a liver biopsy at the time of the gastric biopsy. So early syrups are advanced fibrosis or scarring. And then in protocols, they would undergo another liver biopsy a year later. Two-thirds of the time, there's marked improvement in liver scarring, even reversal of early syrups. The message I give to patients is, you know, you don't have to lose 50 pounds if you have 50 pounds of overweight. Even if you lose 10, 15 pounds, that'd be marked as the journey. You know, I also once said, the journey of 1,000 miles begins with a single step. Yeah. You're also the coffee grower too. You've described how coffee cannot... I would mention that. Thank you. That out. In non-alcoholic fatty liver disease, the people who drink coffee have the least amount of fibrosis or scarring. Published in peer-reviewed based medical shop. Now, why is that? What is it about coffee? I think coffee, my take on it is that in many, many diseases, including obesity, liver disease, Alzheimer's, cancer, inflammation is the enemy. Coffee drinkers have the least amount of intraventory markers. Sometimes your primary care physician, once a year, when you go for a checkup, will do something called CRP, C-reactive protein. If it's elevated, something's wrong. Information. Something's going on. Very serious. Coffee drinkers have the lowest levels of CR. Low information. And it turns out it's not the caffeine. It's even decaf coffee. Decaf coffee has as many benefits, sometimes not as robust. Because I talk about it, I've written a book on coffee, coffee the magical elixir. My colleagues around the country will send me articles saying, Sajji, you've probably seen it, but in case you missed it, here's another study. So one of my colleagues, a tenured professor of hematology and oncology, previously chief of the division of hematology and oncology, and Beth Israel Deaconess Medical Center, Dr. Loel Schripper, good friend, sent me an article about a year ago, published in JAMA, Journal of the American Medical Association on oncology. Patients with stage four colon cancer. It's already spread to the liver, it's spread to lymph nodes, the most advanced stage. Who drink coffee, including decaf coffee, have improved disease-free survival. What? You drink coffee, you live longer? And those dependent. Which adds credibility. So four cups better than three, three better than two, two better than one. I recommend drink two to four cups, drink regular coffee, drink it black. If you don't have diabetes and you want to add sugar and milk, you can add it. I was interviewed by Chronicle ABC award-winning reporter, producer, Nicole Estefan. She sent me a text six months ago, I'm doing a show on coffee, are you interested? I said, Nicole, I wrote a book, let me send it to you. She interviewed me, my home with a video guy. She interviewed nine other people, 30-minute show, it's been aired about seven times. I'm at the start at the end. At the end, she even puts up my coffee book, which I didn't expect her to. But very nice of her. And she said, final question, Sanjay, what's the best way to drink coffee? And I said, Nicole, the best way to drink coffee is to drink coffee with a friend. Then I said, now I'll give you the scientific answer. The worst thing we can do, I hope everyone is listening carefully to this. The worst thing we can do is partake of artificial sweeteners. Diet coke. It changes the blood microbiome, the 100 trillion bacteria that out. The blood sugar goes up. There's three times the risk of stroke. Now there's going to be a warning that these artificial sweeteners can also be carcinogenic. They took cancer. Don't drink. The best drink in the world is water. Next is coffee. And if you're really in the mood to have a soda once in a blue moon, have a regular coke. Drink half of it. Have a regular Pepsi. Don't have diet Pepsi or diet. You're always on point with all things liver, Dr. Chopra. We always get real deep on the subject. I can't thank you enough for being on the show. It's a wealth of information. I take a lot from it. Our audience takes a lot from it. And I just can't thank you enough for your time, for all your knowledge. It's much appreciated. Great to be with you. Mahalo.