[00:00:00] Elizabeth: Hi everyone. I'm Elizabeth Stein, founder and CEO of purely Elizabeth, and this is lived purely with Elizabeth, featuring candid conversations about how to thrive on your wellness journey. This week we are talking all about the importance of the liver and the silent epidemic that is affecting one in four people.

[00:00:24] That silent epidemic is fatty liver disease. And we're talking with our guests, Kristin Kirkpatrick and Dr. Ibraham Hanouneh. Kristin Kirkpatrick is a registered dietician in the Cleveland Clinic Department of Wellness and Preventative Medicine. Dr. Ibrahim Hanouneh completed his internal medicine residency and gastroenterology and hepatology fellowship training at the Cleveland Clinic and served on the liver faculty.

[00:00:51] At the Cleveland Clinic and at the Mayo Clinic, he works with MNGI Digestive Health, one of the largest gastroenterology practices in the United States. In 2017, the two wrote Skinny Liver to address a non-alcoholic fatty liver disease, and their latest book Regenerative. Health is out now. In this episode, Kristin and Doctor Ibrahim discuss why the liver is one of the body's most vital organs having a role in every metabolic process in the body.

[00:01:24] They share the biggest risk factors that lead to fatty liver disease, including metabolic dysfunction, diabetes and insulin resistance. The good news is that fatty liver disease can be prevented and they share the lifestyle changes such as personalized Mediterranean diet, regular physical activity and stress management that can all reverse the disease.

[00:01:47] Lastly, we talk about liver friendly foods, detoxing, and sleep. Keep listening to learn more.

[00:01:54] Kristin and Ibrahim,, welcome to the podcast. It's so wonderful to have you, and I'm really excited to talk all things Liver today.

[00:02:33] Kristin: So it's a good topic, right? We don't talk about the liver enough, so excited to be here.

[00:02:37] Elizabeth: We definitely do not, we're pretty...

[00:02:38] Ibrahim: Excited.

[00:02:39] Elizabeth: Yeah, it's definitely the first time that we're gonna be fully talking about it on the podcast here. And so before we get into your book and your mission, and you've certainly spent a lot of time focused on studying the liver and how we can. Heal it and regenerate it. What is your background? Why? Why did you guys get into an interest in liver in the first place?

[00:03:03] Ibrahim: I trained in Cleveland at the Cleveland Clinic, and that's when I met Kristin. My mentor had a special interest in liver disease, and I did some research with him right after med school, and during my training in internal medicine residency I loved it. I loved the physiology of liver disease, the pathology of liver disease. It's really fascinating, specifically about the capacity of the liver to regenerate no other organ internal organ in the body that regenerate, except the liver. And that's how I met Kristin at the Cleveland Clinic. And we've been working together since.

[00:03:37] Kristin: And it's such, such an honor to work with Dr. Hanouneh. So I'm a registered dietician. And so really the light bulb for me was I had a lot of patients coming to me and saying, Hey, my doctor tells me I have too much fat in my liver. I don't know what that means. He or she tells me there's no drug. And here I am. So what's the diet?

[00:03:59] So really early on, what we realized together was that there, there was no diet, there was no prescription. It was lifestyle, but there was no guide that was out there helping people. And that really was what encouraged both of us to say, you know what? Let's write the guide. Let's give people the opportunity to know how to handle this disease if they get it. And the chances of getting it, if you just statistically speaking look at it, are pretty high. We have a lot of people walking around with this.

[00:04:26] So, that really was my rationale for that. I met Dr. Hanouneh because I begged him to allow me to shadow him for some time. Because I'm not a physician; I just know the diet and I just really wanted to see the medical side of things. And he was gracious enough to say yes. And within 30 seconds, I realized how brilliant he was and I was like, I gotta work with this guy.

[00:04:50] Elizabeth: I love that. So you had your first book together, come out in 2017, skinny Liver, and then this year you came out with Regenerative Health. So why the second book? What was really the impetus? What had changed?

[00:05:03] Either in our knowledge or just in our society?

[00:05:07] Kristin: Well, the disease continued to worsen. In fact, Dr. Hanouneh would probably agree with this, that worsened even more aggressively during Covid just because our dietary habits changed a lot. Our drinking changed. Even though non-alcoholic fatty liver disease is not about drinking, it can exacerbate it, of course.

[00:05:25] So that was one motivating fact. The other was that our first book was really to shed light on this: this is the disease, this is what we're seeing, and here's some dietary principles.

[00:05:36] ..The second book was really to say, okay, you all know what the disease is. You read our first book, hopefully. And so now we're just gonna dive into the metabolic health, into all of the principles from a lifestyle perspective. So we didn't have that opportunity in book one 'cause we had to educate about the liver to begin with. So, that was, I would say that's my reasoning for wanting to do that second book.

[00:05:58] Ibrahim: Yeah. I echo what Kristin said and we've learned a lot actually over the last five, 10 years about fatty liver. Indeed. They used to call it NAFLD, which stands for non-alcoholic fatty liver disease, meaning we used to call it a fat in the liver unrelated to drinking.

[00:06:14] And we've learned over the last five, 10 years that this is a disease associated with metabolic syndrome. And hence the name has changed. We call it now MAFLD, which is metabolic dysfunction associated fat liver disease.

[00:06:29] Elizabeth: Mouthful.

[00:06:30] Ibrahim: Yeah, so technically from MAFLD reflecting the, new science and the stuff that we learned over the last five, 10 years.

[00:06:39] Elizabeth: So now that it's called metabolic and we know that... what is the most recent, 92% of us are metabolically unhealthy. Is that accurate or close to..

[00:06:50] Kristin: That's accurate. The study showed that only 7% of the population is metabolically healthy. So, you're right. Of course there's like plus and minus some degree of error there. So yeah, probably 97%, 96 to 98% is probably an accurate assessment of how many people are not metabolically healthy.

[00:07:09] So

[00:07:09] Elizabeth: So that means that therefore, are we all on this path to fatty liver disease? Could you draw that conclusion or is that a little...

[00:07:19] Ibrahim: Technically, we, are all at risk, let's say we are at risk to develop fat liver disease, hence technically the book Regenerative Health and many other materials, podcasts like yours available out there, to prevent technically us from getting fatty liver disease in the first place.

[00:07:36] Elizabeth: Sure. But I think that's why it's so important. So many of us are metabolically unhealthy, then if we don't change that we're all on a path and therefore this is why this information is so important. Yeah. So maybe a great place to start with the first book is that education for people who aren't really aware of why is the liver one of the most vital organs that we have, what is its function?

[00:07:58] Ibrahim: I can take that. I'm sorry I use this analogy all the time, but I'm just gonna use it again here. Kristin and I, we call the liver a security gate, a TSA gate. Anything comes to your body has to stop, get filtered by the liver before gets in. And when the liver is overwhelmed with fat and, or any disease, the security gate is broken, and some of the bad guys are gonna get in. Some of the toxins will be built up in the system and cause a lot of problem. So the main filter, the main gate, actually that anything comes to our body has to stop by that gate is the liver. That's why it's a really very important organ.

[00:08:35] Elizabeth: And so, as that main gate, what are all the functions that it plays has in the body?

[00:08:41] Ibrahim: So technically, quite honestly, we can spend the entire hour talking about the function of the liver. It's overwhelming, but storage of vitamins, for example storage of glycogen, which can be broken down to sugar during fasting period of time regulate of sugar metabolism, cholesterol metabolism, and filters, like we said, all the toxins from our body. Yeah, we can talk about this for a whole hour, but, generally speaking, I would say regulation of metabolism. So liver disease can lead technically to metabolic dysfunction and then filter of all the toxins from the body.

[00:09:19] Elizabeth: So today the statistic I think is one in four Americans have fatty liver disease. I don't think that many people know that it is as we said earlier, it's this unknown silent epidemic, so to speak. So why, what is some of the biggest contributors today? Why are so many people today living with fatty liver disease?

[00:09:45] Kristin: Elizabeth, you were saying going back to that statistic of how many people are not metabolically healthy, right? Yeah. The 96, 80% are we all on the path? So really when you look at that, and you look at metabolic health. Let's look specifically at insulin resistance and type two diabetes, which we know a huge chunk of the nation has, which would be deemed as poor metabolic health. When you have one of those conditions, you are about 80 to 85% more likely to develop non-alcoholic fatty liver disease. Precisely for the reasons that Dr. Hanouneh went into, which is basically the liver helps in the management of blood sugar, regulation of glucose, et cetera. So, when we cannot regulate that from any kind of level, something's going on in our pancreas, we're carrying too much belly fat, and that is interfering with being able to manage insulin, et cetera.

[00:10:36] That then is a direct risk factor for non-alcoholic fatty liver disease. So I would say, it's probably one of the greatest risk factors. So poor blood sugar managements, belly fats, is going to be a contributor to that. I can't tell you how many patients I have that are over the age of 48, they are going into menopause.

[00:10:55] They're perimenopausal, and their phrase to me is: Kristin, I woke up and I had a belly and I never had one, and now I can't get rid of it and I'm eating nothing. It's like I can't predict exactly what will come out of their mouth after they tell me now I'm in menopause. So we know that's a risk, direct risk factor as well.

[00:11:14] There's irregulation of blood sugar that can occur there, but belly fat can be a huge thing here. So, I would say belly fat is one thing to look at as a risk factor. And then if you have belly fat. Then on top of it, any, let's say two or three factors associated with metabolic syndrome. So that could be high blood pressure, high lipids, high triglycerides, sleep apnea, high blood sugar obviously. If you have those two together, the chances of you having disease are very high.

[00:11:42] Ibrahim: Yeah. I think it might be worth mentioning here, a study that was done in Southern California, highlighting the strongest association between type two diabetes and fatty liver disease. The study was done in diabetes clinic.

[00:11:55] They said everybody who's coming to this clinic is going be screened for fatty liver disease. They did a picture of the liver with MRI and some blood tests to find out if these patients with type two diabetes have fatty liver disease. Now remember, these patients have no history of liver disease, never ever been told that they have liver problem. They have diabetes and they were coming to their clinic for management of diabetes. When you screen those patients for fatty liver, it turns out close to 70% of them have fatty liver disease.

[00:12:25] Elizabeth: Wow.

[00:12:26] Ibrahim: Meaning, if you do have type two diabetes, it's really more likely than not, you probably have fatty liver you didn't know.

[00:12:32] But the scary part of that study, about 10% have significant damage in their liver, scaring tissue in the liver from fatty liver, technically meaning, the liver disease is way beyond advanced than they thought it would be. They didn't even think they have liver disease. So the risk factor that Kristin mentioned specifically, I would say type two diabetes.

[00:12:55] If you have type two diabetes, please tell your doctor you need to be screened for fatty liver.

[00:13:03] Elizabeth: We know that, okay, there's many of us who, if you have this, it's likely you have fatty liver disease. But let's talk about what is, like, why is it bad to have fatty liver disease? Obviously no one wants to have a disease, but what is it really? And then the wonderful thing is that there's a way to reverse it.

[00:13:22] And so what happens, I guess let's start with what is it really and what happens if it gets too far? Is there a point that you can't reverse it?

[00:13:31] Ibrahim: So I would say fatty liver, plain and simple, really, as the name implies it's fat in the liver. If I show you a picture of fatty liver, you will see whitish liver, a lot of fat in it.

[00:13:43] Why is this is not good? Well, it turns out if you got fat in the liver for a long period of time, that fat will break down and causes inflammation. And this inflammation over a long period of time will lead to some scarring tissue. When get buildup, when that scaring tissue builds up, that will lead to technically damage of the liver or cirrhosis of the liver.

[00:14:05] I use the analogy of a car. Early on with fatty liver, you got a lot of scratches and dents on the car from the outside accident. When they build up, they'll affect the engine. The engine may not be working. We don't wanna wait that late.

[00:14:17] We wanna find fatty liver early on when the damage is minimal to prevent the scaring tissue from getting into the engine of the liver and cause problem. So why is this is important? Because it turns it turns out, believe it or not, the most common indication for liver transplantation in the United States is fatty liver disease.

[00:14:38] If you look at the liver transplant program where I live at the University of Minnesota, most of those transplant are done for patients with fatty liver disease. If you look at the most common cause of liver cancer, believe it or not in the western world, is fatty liver disease because this cancer unfortunately likes scaring tissue. And when you have scaring in the liver, that will set the stage for cancer to happen. And that's why fatty liver disease can potentially lead to liver cancer. Now, if you find it early and the good news, it's reversible, I'll I'll have Kristin telling you how to reverse it.

[00:15:15] Kristin: So, I think, really anything that's gonna be related to better or more optimal metabolic health will help in the reversal of fatty liver disease as well.

[00:15:25] If you look at the data, you look at all the studies, we oftentimes use this phrase, what is the perfect diets? I get that question all the time. Kristin, what's the perfect diet? What's the diet that I should be on? Really, your diet needs to be personalized, and there's a lot that goes into it, and that's really important to personalize the diet.

[00:15:43] But if we were to just say, okay, what is the perfect diet for fatty liver disease? The Mediterranean diet is really hard to beat. We have multiple studies over the past five to six years showing that adherence to a Mediterranean diet lifestyle. Style helps in the reversal of fibrosis, which is that inflammation that occurs in those latter stages.

[00:16:02] We also know it's high in antioxidants and it takes out the things that, quite frankly, really damage the liver. It takes out sugar; it takes out refined carbohydrates. So the Mediterranean diet has always been our base. That's probably one of the best indicators of the pattern we should start with, and then we can personalize it from there.

[00:16:22] We can look at that approach and say, okay. I really don't like this on the Mediterranean diet, or I'd like to have more of this. That's where working with a physician or a dietician can really help with personalizing a certain diet to meet your health goal of reversal of fatty liver.

[00:16:38] Elizabeth: And so that's where in the book you've identified these four different metabolic types 'cause we're all not the same, right? And so this is really a way to personalize it.

[00:16:50] Kristin: It's a way to personalize it. I would say that another reason why the metabolic types were so important to us? I can speak for myself. I know Dr. Ibraham and I have had multiple conversations of this, but for many patients, for many years, we would go to the chart, we would open it up and their status would be identified through BMI.

[00:17:12] So we would see that this person is obese or this person is overweight, and it would all be about BMI. Really, if we look at BMI, it is not a perfect standard to health. And so that's why we really develop these metabolic types. We wanted to look at what is your waist circumference, which is a much better indicator, right?

[00:17:30] And even looking a little bit at that height to waist ratio and then how does that combine with your numbers? How does that combine with your lipid panel, with your hemoglobin- A1C? That's how we really came up with those four metabolic types and yes.... Elizabeth it is the most personalized approach we could take in a book form, right?

[00:17:50] Without having a patient sitting across from us and getting their full history. This was the best way to say, okay, this dietary approach might make more sense for you.

[00:17:59] Elizabeth: So while there's no one size fits all, there certainly are certain foods that are better and going to help heal your liver, and certainly things like sugar that are gonna be the worst things for your liver.

[00:18:11] So that's, talk a little bit about those top 10, top 12 foods that you recommend that are the most healing for our liver.

[00:18:21] Kristin: Sure. So, I'd like to start with extra virgin olive oil, which is just an amazing food that we have. We can utilize it obviously in cooking. We can utilize it by simply putting it on top of fruit or salads.

[00:18:34] People I know have put it over ice cream, but there's a lot of usage for extra virgin olive oil. There's a lot of confusion as well as to, okay, how do I actually buy olive oil that is legitimately a hundred percent olive oil that has all the polyphenols, that has all the benefits, right? So there's like that bucket, which we do go into in the book, but I would say extra virgin olive oil is really at the top of my list because there's so many benefits that we see in the data.

[00:19:02] Green tea is another one that we see is very helpful. We know colorful berries, really colorful foods in general. I tell my patients instead of focusing on this like government recommendation of seven to 12 servings of fruits and vegetables, let's just aim for seven to 12 colors every day.

[00:19:21] Because if we're just getting color, we're getting that benefit. It's just easier to wrap your head around. So I would say anything that's colorful would also be really beneficial. Nuts and seeds, lentils.

[00:19:34] I know Dr. Hunouneh loves to talk about coffee, so I'm not gonna mention that. I'm gonna let him mention it, but coffee's probably above extra virgin olive oil. I would say wild salmon or other places where you can get those omega threes. So walnuts would be a great example. Flaxseed chia seed. And I'll let Dr. I Abraham take on the coffee one.

[00:19:54] Ibrahim: Oh yeah. I love coffee myself actually. And that's when I am drinking despite, it's almost 5:00 PM here. But people ask me all the time about supplements and herbs and detox for liver, yeah, Kristin and I, we always say, don't waste your money. The only supplement that has been proven in research over and over to be the most beneficial for the liver, detox delivered, if you will, would be coffee, specifically black coffee. Once you start mixing it with the cream and sugar and other things, you may dilute the benefit. So ideally it would be black coffee. Ideally it would be two cups a day, like too much of a good thing can be a bad thing.

[00:20:32] Coffee is good for the liver, but it's not good for high blood pressure. It's not good for anxiety. It's not good for sleep. So, you got to find your balance. Typically, I tell my patients, if you could do two cups a day, that'd be great, that would be quite helpful for the liver.

[00:20:48] Now the second question, I guess, why coffee? What's in the coffee to detox, deliver? That's a million dollar question. It's quite honestly a hot area for research. A lot of researchers out there trying to investigate what's in the coffee to detox, deliver.

[00:21:01] Not all of us like coffee. I think one day hopefully will be able to isolate what's in the coffee and put it maybe in a pill and that could be helpful. We're not there yet. Both caffeinated and decaffeinated coffee works. Caffeinated probably works a little better than decaf, but there are studies on decaf to be also beneficial.

[00:21:20] Green tea or English breakfast tea, maybe not as beneficial as coffee, but there are some studies supporting its benefit to detox liver.

[00:21:29] Elizabeth: What about coffee enemas? Are those beneficial?

[00:21:35] Ibrahim: No yeah. No, unfortunately. Yeah, I get this question all the time, but no, some practices use that, but they're not beneficial . We've seen some irritation in the colon from that kind of practice every now and then. So, no.

[00:21:48] Elizabeth: So one of the things that I think thought was really interesting in preparing for this and just learning a little bit more about the liver is that unlike any other disease, there's no pharmacological or surgical solutions for fatty liver.

[00:22:04] Which I thought was a really interesting way to think about it. And so you are really relying on what's on your plate as well as lifestyle. 'cause it's not just what we're eating, right? So what are those other areas in our lifestyle that we should be thinking about that both contribute to and can help also reverse.

[00:22:25] Kristin: Sure I can take that. And, you know where I would start with this one is just to say that when we wrote the book and the book was already printed and everything, there was no pharmacological solution Since the book came out almost within the same week of it coming out there, there was the FDA approval of the first drug, which is very exciting. Dr. Hanouneh probably knows a lot more about that drug from being a physician than I do, but there is an option there from a drug standard. I don't know if it still works great if you don't look at lifestyle, right? Yeah. Just like people that are on GLP-1 agonist drugs, that's one component you have to add lifestyle in.

[00:23:00] So what are some of those lifestyle indicators that we look at? Obviously physical activity are going to, that's gonna be really important. I have a lot of patients that are, they're intimidated by physical activity 'cause they're not used to doing it. So one of the things I always say is, you don't have to run a marathon.

[00:23:16] Just find activities that you love and that could be walking or that could be that you like to get on a bike, right? What do you love? Whatever you love, you're gonna continue to do. Then find a combination between aerobic and anaerobic activity. So looking at the combination of resistance training, and if you don't have weights, just use your own body weight or using some sort of exercise equipment.

[00:23:38] And then the aerobic would be running, walking, jumping, anything like that. But try to get some sort of physical activity every day, even if it's just 15 minutes. And so I think that's a big point we wanted to make is that people think. Well, I only have 15 minutes. I don't have time to work out.

[00:23:58] If you have 15 minutes, go and lift a few weights. Go walk around the block for 15 minutes. That has such a huge benefit. So that would be one reducing toxins other place in your life, right? Dr. Hanouneh talked about how the liver is the main detoxifier, so when it is damaged, it cannot really detoxify the way it should, not at its optimal level.

[00:24:20] So finding other opportunities to do that. That could be looking at foods that have more clean, organic, or just better ingredients, right? That's a great example. I know we both recommend your product line a lot because of the clean ingredients there. So, from the detoxification standpoint, that might make a lot of sense.

[00:24:37] You can't always control where you live, but if you're in a place that has a really high level of pollution, maybe you're not gonna run outside. Maybe you're gonna take your walks in indoor where you don't have to inhale that. So trying to find other places to detoxify. And then the last thing I'll say for lifestyle would be sleep.

[00:24:55] I think sleep is often not talked about enough, but it tends to be one of the most important factors to our health span. Right? And our health span is obviously the number of years we live enjoying good health. Different from lifespan, which is simply the number of years we live. So we look at health span reversal and prevention of certain diseases, prevention of things that are brain related, like dementia and Alzheimer's, which is a type of dementia.

[00:25:24] Sleep plays a huge role here. Sleep plays a huge role. We focused a lot in the book on sleep. How can you get better sleep? How can you set up your bedroom for better sleep, et cetera.

[00:25:35] Elizabeth: What's one of your favorite ways to get better sleep personally?

[00:25:39] Kristin: I noticed for me, and this was from like my own investigation into this for the book, that keeping a consistent schedule really worked for me.

[00:25:49] I have two young kids. So what I was doing beforehand was sleeping in on Saturday and Sunday. I don't have to get up at the crack of dawn to take them to school and get ready for work. But I noticed if I go to bed at the same time every single day and wake up at the same time every single day, we have data to show the power of that.

[00:26:08] But we also know that can benefit health. And then the other thing I'll quickly say for better sleep, which like changed my life, is a really good sleep mask. I just didn't realize how good, a good sleep mask could be.

[00:26:23] Elizabeth: What's the sleep mask that you have? I think I need to get one of those.

[00:26:27] Kristin: I have a cheap one from Amazon. I tried all the expensive ones, and they were hitting my eyelashes. So I guess the ones that have, they're more like a cup.

[00:26:36] Elizabeth: Okay. Well, it's Amazon Prime Day tomorrow, so yes, it's on Prime Day.

[00:26:41] Kristin: I'll find the brand, I will text it to you. It's like I'm looking at it right now in the corner . It's cheap, but it is so effective. It blocks the light. So I find that I sleep better and I don't wake up as much. And then I'll say one more thing. As someone who is perimenopausal, menopausal, I purchased something called a bed jet. Which is basically a machine that blows cold air into your top sheet.

[00:27:07] I got one for basically every bed in my house.

[00:27:11] Elizabeth: That sounds amazing.

[00:27:12] Kristin: The bed jet is worth every single dime because it blows in that cold air. And so if you're someone who has hot sweats or just sleeps hot, those are my three things.

[00:27:26] Elizabeth: I love that. Well, it's just incredible. I think the amount of information that we now have about the importance of sleep and how that's now becoming so much more part of the conversation where it's no longer I don't need to sleep. And you're almost seen as a positive for someone, right? Who's, just working or doing, being productive and not taking that time to sleep.

[00:27:46] And now the reality is we sleep and I fully feel this way is like one of the most important things in my day. So I am in bed by 8:30, get up by six, but I really focus on my sleep and feel so much better, right? So much better. But I do now with it getting lighter in the morning, I even have blackout shades, but it's coming through on the side, so I'm waking up to light, so I need that sleep mask.

[00:28:12] Kristin: You need the mask. You need the mask.

[00:28:16] Ibrahim: What about stress? How does that play? Have a role on our liver.

[00:28:21] Kristin: You wanna take that one?

[00:28:22] Ibrahim: Sure. Yeah. Quite honestly, I'm a gastroenterologist in addition to being a liver doctor, and I see that stress has a huge impact on the GI tract in particular and the liver., I mean we have a lot of nerves in our GI tract and quite honestly, when you're stressed out, those nerves start speaking to the brain when they're not supposed to, and they send signals, which can lead to all sort of GI problem, meaning your eating habit would be completely different if you're stressed out. And that's obviously will have effect on the liver. When you are eating, habits have a change when you're not eating the right kind of food that will have an impact on fatty liver disease. Stress also may have indirect effect on the liver. Obviously, when you stress out that will affect sleep habits, which you know, by by itself will cause will have some effect on fatty liver disease. When you stress out, like we said, you may not have the energy to exercise that much.

[00:29:21] So there are some, in short, direct and indirect effect of stress on on our GI system, in particular , and also on the liver.

[00:29:31] Elizabeth: Yeah. I was just even thinking of just even if you don't realize, even if you're eating the same and you're exercising the same and sleeping, but just that parasympathetic sympathetic system getting pushed with that stress. Sometimes we don't realize it, and it's having that sort of silent effect inside of our body.

[00:29:49] Kristin: Sure. Yeah, and the increase of cortisol, right? Like we know that there's damage that can be done when cortisol is consistently high. So, stress management is so key.

[00:30:00] And I think it's another factor why, being in a practice or seeing a practitioner that is part of a multidisciplinary team is so important. I know that Dr. Ibrahim has that component in his practice. I know at Cleveland Clinic, where I am, at integrative medicine, we have experts that can help you with stress management because I'm not trained to do that.

[00:30:23] And so it's really important to find someone you trust that has other people working for them that you also trust that can manage all these components of health.

[00:30:31] Elizabeth: Yeah, absolutely. So going back to what we were talking about a little bit earlier, about detoxing the liver and certainly mentioning that, food is certainly the best thing, but are there any sort of detoxes that when people hear like this is a great liver detox or X, Y, and Z, is there anything that is good that we should be doing to detox liver?

[00:30:55] People want a quick fix.

[00:30:58] Kristin: I know I get this question a lot, right? Oh, I'm gonna do this detox. And my answer is always, take the money you would spend on this detox and go buy some vegetables and Scott's gonna do a better job. But, I think one of the things we wanted to maintain within both books and within our guidance is an evidence-based approach.

[00:31:17] So if we simply look at the evidence on detoxing agents that people could buy, there is no evidence to show that these things help. So that means that some of them could be neutral, that they're not really gonna help much, but they're not gonna cause any damage. But then of course there's some that could cause damage as well.

[00:31:37] They could have other things within them, herbs that might not be really friendly to the liver. They could have things in them that might interact with medications. They could cause electrolyte imbalances. So, if we don't have the evidence for it, if we don't have randomized controlled trials showing, hey, these three detoxes are really where it's at.

[00:32:00] Then we can't recommend it. Sure. But the other thing I would say too is that if you look at populations such as the Blue Zones, right, that live much longer than anyone else, that are happier than anyone else and that don't have disability. I can tell you, with all certainty, they are not going to the drugstore and buying liver detoxes.

[00:32:20] So really that's the example I sometimes give my patients. Look at people who have a much simpler life, don't have access to maybe the financial means that you have to buy every supplement in the book. Maybe they don't live next to a Whole Foods. They're living longer than us.

[00:32:36] They're living better than us. What does that tell you? What does that tell you? So I don't recommend detoxes. I just think again, you can take your money and find a much better use for them.

[00:32:47] Elizabeth: And so same with any supplements as well, any supplements that you recommend.

[00:32:53] Kristin: There are some good supplements that we do recommend that I could say I recommend for my patients. Vitamin D is very poorly recognized and absorbed in the body. So many of my patients are on vitamin D from a liver perspective a lot of my patients might also be on fish oil, so DHA/APA, especially if they don't eat fish. So that could be another one. If they're struggling with other nutrient deficiencies, I might also consider a B complex, a magnesium might be another one that I might consider. But those are probably like down the fairway of where I would look at my supplements. So milk thistle or dandelion? Yeah. Again, if you go to some of the resources like.

[00:33:35] Yes, there could be some small studies that show that dandelion could be beneficial, but, and I'll let Dr. Ibraham talk about milk thistle. But I think sometimes we just take these supplements without making any consideration to other things going on in our life. What medications are we taking? What else is going on? We don't question that. And obviously the supplement industry is unregulated.

[00:33:57] That doesn't mean that there's not good supplements out there. I have almost all of my GLP-1 patients taking creatine right now. Right. And I can tell 'em exactly what is a great brand, what's a great source exactly because I have done the investigation. But that's just an example of when we go to an unregulated place to buy something that we may have seen on social media.

[00:34:22] It doesn't mean that is going to help us. In fact, it could actually harm us.

[00:34:25] Ibrahim: Quite honestly, I don't have much to add beyond what Kristin said. It may worth mentioning vitamin E. There are some studies that vitamin E can decrease inflammation and deliver in patients with fatty liver disease.

[00:34:38] Because it's antioxidant studies actually uses high dose of vitamin E, which is the prescribed dose. It's not the one that you see over the counter. The problem also, if you have fatty liver disease, it's a lifelong disease and it turns out if you use vitamin E at a high dose over a long period of time, that could have potential side effect.

[00:34:59] So anyway, I feel maybe vitamin E is worth mentioning, but probably at smaller doses if possible. Milk Thistle comes all the time. There is not even a week that goes by and I don't get this question from my patients. How about milk thistle? So

[00:35:13] Elizabeth: It's like number one Google thing when you type in...

[00:35:17] Ibrahim: for sure. Yes. I wish it worked. I really do. It doesn't. Now, make no mistake, it's not harmful to the liver.. But it just doesn't work. And it's one of those situations, like Kristin said, save your money for something better for vegetables and other things. It doesn't work really, you know the story of Milk thistle if we have a second. The story of Milk thistle and liver disease came from back in the days they used to use it for mushroom poisoning. There are certain kind of mushroom poisoning to the liver. It's rare, but it does happen. I've seen a few cases when I used to work in Cleveland and it turn, it turns out in that situation in particular, Milk Thistle may work, but beyond that Milk Thistle doesn't work for fat liver disease, in particular. I'm not against it, but I do not recommend it because it's just not beneficial.

[00:36:07] Elizabeth: Okay, so one other hack question. I know that liver detox is not good, but one of the things that you hear about is, say, loading up on greens. Is there a fact to that and is that beneficial to say, let's put all, I think certainly for any diet, we wanna think about filling our plate with leafy greens, but is it beneficial to say, let's do spirulina and algae and really.

[00:36:35] Adding the most amount of alkaline greens to the diet.

[00:36:39] Kristin: I think there's benefit to greens of any capacity, right? So whether it is a marine type of plant like algae or spirulina, there's definitely benefit there. We have a few studies looking at fatty liver and spirulina, or whether it's bok choy or kale or spinach.

[00:36:56] I think like when we talk about this term of loading up. I find in my patient population that term is pretty subjective. Yeah. So some people might consider loading up as, I'm gonna have a huge bowl of it. Others might look at it as, I'm going to eat it all day long. So, we always wanna have balance.

[00:37:13] If you're just eating leafy greens, then you're probably missing some vitamins and minerals from some other things that maybe you're not getting. But I do think, I think about the mind diets, which obviously is a diet for dementia. The dash diet, which is a diet that's more related to the heart.

[00:37:30] Both of those, if you follow a diet for your mind or your heart, you're gonna benefit the liver because they're so similar in the benefit that they get. Leafy greens is a component of both of those diets. So I would say if you're able to get at least two servings of leafy greens a day, that's huge. That's huge.

[00:37:49] But then let's look at some other options, too. And if you love green, then maybe let's look at some broccoli. Let's look at some green beans. Right? So we can stay within the green family. But again, I would like if you're doing leafy greens to get a variety of other fruits and vegetables as well.

[00:38:04] Elizabeth: So getting that

[00:38:05] diversity in the diet really.

[00:38:07] Kristin: Exactly. Yeah. 'cause I think, if you load up on anything, you're gonna get bored of it. It's just a matter of time, right? So giving a little bit more diversity. E even looking at if you're gonna make a smoothie, that's a great place to put spirulina.

[00:38:21] That's an easy, that's an easy win right there. So you know, things like that where you could add things that are green, that might not be something in a bowl that you consider to be a salad can still give you benefit as well, for sure.

[00:38:33] Elizabeth: All right, so we talked about all these wonderful things that we can be adding to the diet to regenerate, but we haven't truly touched on what are like the worst offenders for the liver.

[00:38:44] I mentioned sugar, but what are some of the others, and let's touch upon that.

[00:38:48] Kristin: So sugar obviously is one of the worst offenders. Refined carbohydrates are one of the worst as well, but for the exact same reason that they have a huge impact on blood sugar and insulin. So what we tried to do in the book was really say if you're going to have something that has sugar added in, not naturally occurring, right? We wouldn't tell people don't have fruit. But if you have something that has sugar added in, make sure there's fiber attached to it somewhere, right? Because we know that fiber slows the absorption of sugar into the bloodstream, slows how much insulin you need, et cetera. We refer to it in the book as competition for digestion.

[00:39:25] So anytime, like if you have a piece of licorice, there's no competition. It's just this is awesome. I love this. Sugar breaks the veins, insulin, your blood sugar, they skyrocket, you're on a high, you feel great, and then they drop and then you feel like crap. Guess what? You need to get that high again.

[00:39:43] You need more licorice. So fiber slows that process down. So you know, really it's unrealistic to say. Never have sugar ever in your life because there's a lot of products that might have some added sugar. So, we don't wanna be that stringent because it's just not realistic. But if there's fiber attached, that's gonna be a better choice for you.

[00:40:05] And then the other thing I we talked about is let's look at an 80 or a 90 10 approach, right? So if 90% of the time you're eating a diet that looks Mediterranean in style, that is, really helping with your metabolic numbers. You know what 10% of the time have the cookie, 10% of the time have something that you really enjoy that really speaks to you.

[00:40:27] It's not the 10% of the foods we eat that are going to ruin our liver. It's when the 10% becomes the 90%. So I would say refined carbohydrates, we focus on that a lot. Anything super, super high in carb that might be problematic for someone who's really struggling with blood sugar management? And even though alcohol's not a cause of non-alcoholic fatty liver disease, omitting or really limiting alcohol while you're trying to reverse the condition can go a long way.

[00:40:54] Right. We're gonna move into some rapid fire q and a.

[00:41:04] What are your personal top three lifestyle habits to feel your best?

[00:41:09] Ibrahim: For me would be low carb, particularly on a weekdays playing tennis and drinking coffee.

[00:41:16] Elizabeth: And do you have a favorite coffee brand that you buy? The best coffee I.

[00:41:21] Ibrahim: Oh boy. I I don't have stocks in Starbucks, but honestly I do like Starbucks.

[00:41:29] Kristin: I would do sleep. I think the sleep is really critical. I loved what you said, Elizabeth, about going to bed at eight 30, I think you said at waking up at six. That's about my timeframe as well. Sometimes my kids screw that up, but that's around my timeframe. Adding in some extra virgin olive oil.

[00:41:45] Every day. So even if I don't have a salad, finding a place to do that, a lot of times I'll just take a shot. And do you have a favorite olive oil? I have done some olive oil tastings with Cobra Estate, which is out of California. I love their olive oil, and it's like they provide me with all of their data, so I know the quality of it.

[00:42:06] And so I'm always looking for quality, but I think it tastes really good and it's got different varieties in terms of mildness and things like that. So I like that. And I think I really love weightlifting. I think weightlifting is really important for women, especially as we get older.

[00:42:22] I love, biking and I love running and all those things, but I feel the strongest when I lift some weights and I, that whole thing, I said about 15 minutes. Even if I have 10 minutes in a day, lifting a few weights, just that's what I need to feel good throughout the day.

[00:42:36] So I would say those are my big three lifestyle things.

[00:42:39] Elizabeth: Love that. I'm big into weightlifting right now too. Feel like after this I'm gonna do take my 10 minutes and now maybe do that.

[00:42:47] Kristin: Right. Do some pushups.

[00:42:48] Elizabeth: Yeah. Favorite words to live by.

[00:42:53] Kristin: Gentle, I think is a good word. And we can use that word for a lot of I think of gentle nutrition.

[00:42:59] So that's having the cookie, right? Go easy on yourself. So I think gentle is really important. Real,. I think real is important. So some of the things, when my patients talk to me, some of the things they say to me is, oh gosh, I feel like you're such a real person. I often ask them, well, what what's a non-real person in terms of dietetics?

[00:43:20] And they're like, well, they're just someone who gives me a diet and says don't eat this, and this. Right? So I think that's another one to think about as well. And then the third word I would use is smile. I don't think as a society we smile enough. And I just find, even if you're at the grocery store and someone looks like they're having the worst day and they're flashing you a dirty look, it's probably not geared at you.

[00:43:44] And if you smile, that person usually smiles back. And that could help lower their stress, even for that one second. So those would be my three words. I love that.

[00:43:53] Ibrahim: Yeah. For me would be, food. I would say, a wise man once said, let the food be your medicine. I always remind my patients is you may not need the medicine if follow the right healthy diet.

[00:44:05] Another one would be love or family. I tell my patient all the time, you do it for your loved one, you got to take care of yourself. Because it's not just about you. You don't wanna hurt the people around you and you wanna, be healthy for them.

[00:44:22] Yeah. I feel those are my, the two I can think of now, right now.

[00:44:26] Elizabeth: Those are great. Three items in your grocery cart, always. Not purely Elizabeth.

[00:44:36] Kristin: I have that in my pantry though right now. Three items in my grocery cart. We see kale. Not everyone loves kale, but I happen to really kale. I like la. I do not Kale. There is a kale salad that true food does. And oh's such a good one. It's so good. Right? And I worked for months to try and copycat it.

[00:44:54] And I finally nailed it. And I feel like I make that at least three times a week. So that's definitely gonna be something there. The other thing in my grocery cart is most likely going to be walnuts. I love wa, I love nuts in general, but walnuts give you that Omega-3. So I really love, and they're so versatile.

[00:45:13] They're so meaty. So I love walnuts. So that would be another thing in my cart. The extra virgin olive oil is not always in my cart. 'cause I buy I get like a huge container and it's in my pantry. So I go, it takes me a long time before I need to purchase it again. I'd say probably the third thing would probably be turmeric.

[00:45:31] I use a lot of turmeric in my cooking. I'd much rather use it in the that form versus a supplement, which sometimes is very popular with my patients, and I like finding different ways to use it. So those would be the three things that are typically always in my car. What's your favorite way to use turmeric?

[00:45:47] I love using turmeric on eggs, actually. Ooh. So, yeah, actually our chef at Cleveland Clinic Integrative Medicine taught me that. I did not come up with that on my own. Yeah. We used to have our patients groups, and we would do a cooking class with them, and one of the things we would make is an egg white omelet with all these vegetables and just a ton of turmeric.

[00:46:08] And it was just so good. It was so delicious. And so I, I've really continued doing that. So that's one of my takeaway.

[00:46:15] Elizabeth: Yeah. I'm definitely gonna try that tomorrow. Yeah. Yeah. How about you Abraham?

[00:46:20] Ibrahim: I love fruits quite honestly. I probably eat a little too much fruits if there is such thing I love seasonal fruits. So, these days, cherries, particularly those one from the West coast, Seattle area. I try to have greens, quite honestly, always in my grocery cart. I like cucumbers. So that's frequent one in my cart. And then I love nuts, for all the good reasons.

[00:46:44] Kristin mentioned, of course, too much of good things can be a bad things, so too much nuts can leads to weight gain and much fat into your system. But President Obama used to say seven nuts every day seven , cashews or whatever every day.

[00:46:59] So I try to stick with that.

[00:47:01] Elizabeth: And last question. What is your number one non-negotiable to thrive on your wellness journey?

[00:47:08] Kristin: Oh boy. Number one, non-negotiable to thrive. Gosh, the thing that when I use the non-negotiable term, too with my patients, a lot of them say bacon, and I usually agree with them. But I wouldn't associate bacon with thriving.

[00:47:24] So I'll just say bacon is probably my non-negotiable. I probably have it once a month, and I love it once a month. It's delicious. I don't think it helps me with thriving. But I don't know,

[00:47:35] Elizabeth: maybe even finding joy in your life.

[00:47:37] Kristin: Finding joy. Finding joy, finding the opportunity to bring things in that don't make you feel guilty or bad or shameful.

[00:47:46] Right? So maybe there's the thrive associated with process meet.

[00:47:54] Ibrahim: Yeah, for me, I grew up in in the Middle East. And I love baklava. Being a fatty liver doctor, if you will. I try not to eat baklava every day, but if I feel like, if it goes at least like once a week, once every other week, I try to have some baklava. Otherwise I feel like, feisty a little bit.

[00:48:15] Elizabeth: Well, I love that. In closing, where can everybody find you and anything that you wanna share that's next that we haven't touched on?

[00:48:25] Kristin: I think like we're always looking at new data. We're always looking at what's coming up with new studies, with potentially new drugs. And so the best way for us to update, at least for myself, is through my social media profile.

[00:48:37] So, fuel well with Krissy. I always think if you fuel well, you feel well. So fuel well with Krissy is my Instagram and Facebook handle. And then my website is Kristinkirkpatrick.com and Kristin spelled with an I.

[00:48:50] Ibrahim: Yeah for me, I must admit I'm not quite active on the social media. I'm guilty about that. But Kristin and I connect on a regular basis and, and keep each other up to date on stuff. I practice in the Twin Cities Minnesota. I see patients in the clinic with fatty liver disease and liver disease in general.

[00:49:07] Elizabeth: Wonderful. Well, thank you both so much for being here. It was such a pleasure to meet you.

[00:49:12] Kristin: Thank you. It was a privilege. Thank you.

[00:49:13] Elizabeth: Bye. Thanks so much for joining me on Live Purely with Elizabeth. I hope you feel inspired to thrive on your wellness journey. If you enjoy today's episode, don't forget to rate, subscribe, and review. You can follow us on Instagram at purely Elizabeth to catch up on all the latest.

[00:49:34] See you next Wednesday on the podcast.