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My guests on today’s episode are Kristin Kirkpatrick MS, RDN, and gastroenterologist Dr. Ibrahim Hanouneh, co-authors of ‘Regenerative Health.’ This groundbreaking book unveils the secrets to identifying your metabolic type and revitalizing your liver for lifelong health. Our conversation dives deep into the multitude of strategies for safeguarding and rejuvenating your liver, thereby enhancing overall health and wellness. Discover the vital role your liver plays and learn practical tips for its upkeep. I love how the two have partnered together to provide a physician’s point of view and for nutritionist’s day-to-day approach to best practices.

Resources Mentioned:

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  • 00:01:12- The Start of “Regenerative Health”
  • 00:02:19- Pioneers for New Lifestyles
  • 00:03:45- What Prevents Us?
  • 00:09:04- Focus on Overall Health
  • 00:11:11 – Four Metabolic Profiles
  • 00:14:30 – Cultural Differences
  • 00:15:21 – Why Focus on the Liver?
  • 00:18:26 – What is the Calling?
  • 00:19:41 – How the Liver Impacts Health
  • 00:21:19 – The Effects of Stress
  • 00:23:11 – Starting a Liver Health Meal Plan
  • 00:26:35 – Processed Sugar in the Gut
  • 00:28:56 – Improving the Gut Microbiome
  • 00:31:51 – Get More Veggies
  • 00:33:06 – Different Sugars’ Impacts
  • 00:35:45 – The Liver on Keto
  • 00:39:49 – The Effects of Exercise
  • 00:43:16 – Too Far Gone?
  • 00:46:12 – What About Hydration?
  • 00:50:28 – Trendy Cleanses
  • 00:52:18 – Wading Through the Confusion
  • 00:54:55 – The Truth About Oils
  • 00:56:04 – Teaching the Teachers
  • 00:57:51 – Success Stories

Show Transcript:

[00:00:00] Gabby Reece: Hi everyone. Welcome to the show. My guests today are Kristen Kirkpatrick and Dr. Ibrahim Hanouneh. And they have gotten together and written a book called Regenerative Health that is out now, and they decided to write this book because what they talk about is that fatty liver disease is a silent epidemic.

Most people, a lot of people actually don’t know that they even have it. They’ll say, oh, I feel extra tired. Or people think it’s for someone who’s very overweight or has diabetes, and it is not the case. And one in four people will end up with fatty liver disease. And the good news is they break it all down for you signs that maybe you have it and what you can do to turn back any damage that you’ve done to your liver.

And one of the things that Dr. Ibrahim really stuck with me is that the thing he loves about studying the liver and working with the liver is how regenerative it is. So they say, yes, sure, we’ve got this issue. And guess what? There’s so many solutions to it. So I hope you enjoy our conversation.

Hi everyone. Welcome to the Gabby Reece Show. It’s my favorite thing to interview two people at once far away. Okay.

[00:01:10] Kristin Kirkpatrick: We’re good at going with the flow.

[00:01:12] Gabby Reece: We are good. So let’s start there. So your new book will be out Regenerative Health. And just maybe give us the background on how the two of you decided to take this project on together.

[00:01:27] Kristin Kirkpatrick: So I’ll I can answer that. We actually collaborated with our first book, Skinny Liver. We were both working at Cleveland Clinic at the time, and I really wanted to focus on non-alcoholic fatty liver disease. I had so many patients and they had no guide. They had no. Nothing to direct them of what to do.

And I thought, I wanna write the guide. But I realized I couldn’t do it without a world-class hepatologist. I met Dr. Hanane, I was able to shadow him for some time, which was fascinating to me. And that’s how we connected.

[00:02:00] Dr. Ibrahim Hanouneh: No, yeah. Thank you very much for having us. It’s really an honor to be with you today.

And and, yeah I echo what Kristen said. It’s been a wonderful journey to work with Kristen and we chose specifically fatty liver because it’s a disease that has no medicine. It’s like a wise man once said, let the food be on medicine. That’s a perfect example of fatty liver disease.

[00:02:19] Gabby Reece: I have seen in having all these conversations a movement of people like yourself and like Kristin, who one would say are traditionally trained, but then are moving in this other direction and trying to bridge the two worlds of hey, lifestyle and health and medicine.

But I’m always more curious with someone like you who is well-trained and this is what you do. The willingness ’cause in a way it’s not that it’s a risk, but you have to be a bit of a pioneer to go, wait a second let’s get people to, have different lifestyle practices. So what about you and your past or your background gave you that freedom to even have this conversation?

[00:03:01] Dr. Ibrahim Hanouneh: I’ve always believed that in really, once again, let the food be your medicine. If we can fix it with lifestyle changes wouldn’t be way better than being on a medicine the rest of your life. Considering potential side effect not to mention lifestyle will if you will kill two birds with one stone or effect several components of metabolic syndrome when we nothing against medicine, but, finding a medicine to treat fatty liver would be fine, but wouldn’t be much better.

If I focus on lifestyle and affects the all components of metabolic syndrome, diabetes, high blood pressure, high cholesterol, overweight, and as a result of that fatty liver, I think, that will be big pictures or a good investment for the future.

[00:03:45] Gabby Reece: I wanna get into the different types of metabolic profiles, but be, but before we do that, I I always ask a lot of my guests, ’cause you guys see people all the time and I know that we are actually equipped with the information. We have it right. We know we need to get to bed, we know we probably shouldn’t have sugary drinks. There’s a lot of things we know and I’m curious individually and Kristen, I’ll start with you.

What is it that is stopping us? And you talk a lot about kind of emotional and mental health in the book, conversely with, metabolic health and microbiome and your gut health. But I just wonder just from a human part, what each of you is seeing that you really think are some of the most common reasons that it’s so hard for the general population to get there.

[00:04:38] Kristin Kirkpatrick: Yeah, it’s really hard. I’ve seen that really throughout the course of two decades of seeing patients. And I think one of the things that people lose when they’re trying to change behavior related to food is everything outside of food. So you specifically mentioned sleep as one aspect. I also look at social circle environments your childhood.

I think sometimes we minimize just how much our childhood really gives us a perspective of how we eat as an adult and how hard it is to change that. So we focus on food, but then we’re not focusing on anything else. So I think that’s one of the real hard things about behavior change. I also think sometimes we try to be less than human.

So I always tell my patients, when you come to see me, I wanna know what your non-negotiable is. And everyone’s got one. It’s typically bacon, right? Or something like that. But what’s the non-negotiable? So I don’t think that you have to give up the foods that you love. You just have to have less of them.

And once we start getting really restrictive in some of our dietary patterns, it’s so much more difficult to stick with them. And we end up taking on foods that we don’t enjoy and we’re not looking at our cultural preferences, our personal preferences, all of that is really important. So we have to look at everything that surrounds why we put something on our plate and examine that first before we’re gonna look at behavior change.

[00:06:01] Dr. Ibrahim Hanouneh: Yeah. If I may add Kristen and I were talking yesterday about a study that looked at, all sort of diet to treat metabolic syndrome. They looked at the keto diet, the low-carb diet, the Mediterranean, etc. It turns out the most effective diet to fix metabolic syndrome or fatty liver is a diet that you gonna be able to stick to it because this is a long-term journey, and you got to, find the healthy diet that you like by the end of the day.

The other things if I may add it turns out it’s it’s way more effective if you do it as a team, meaning as a family it give you a little bit more incentive to do things and and become more successful.

[00:06:42] Gabby Reece: Yeah, I think that, I think the environment is such a big one.

Not only like what you do or don’t have in your house, but I don’t wanna, I’ll get, this is a terrible analogy, but I. I do crave a lot of red meat. I’m genetically very low in iron. There’s a bunch of things to it. And so my husband’s always oh God, red meat, so I will make him this beautiful, fish and something else.

And we, we cook healthy in our house, but then I’ll make a little tiny filet for myself, and I see him looking across at me like, are you serious right now? So I think it’s even, that’s a terrible example. Those are two kind of healthy foods. Imagine if one person’s sitting there with their salad and their homemade dressing and their partner’s sitting there with a burger or a slice of pizza.

I just think it, no matter who you are, my point is it’s like no matter who you are, I think it’s really hard to do it if your environment isn’t on board. Do you tell patients, Hey, listen. Let’s you, Kristen, I love the non-negotiable part, but do you feel like it’s let’s take out some of the worst habits a little bit, not about restriction fully, and then as people make progress, feel better, look better, then they’re even more motivated to continue and take out the things that really block them from success?

[00:07:53] Kristin Kirkpatrick: Yeah, for sure. Because I think that it’s a progression and you’re absolutely right at the beginning, it’s really difficult, right? I’m seeing all these people now that are seeing me for New Year’s resolutions and here’s what I wanna do in 2000 twenty-four. And my question is always why didn’t you see me in October?

Why did we wait till this obscure date to start this? But it’s a really hard time because people are starting these new behaviors. Once they start dropping weight, once they see results in, let’s say their lipid panel looks a little better, then they’re motivated and they start making other changes.

So I think we need to be a little better. What I see with my patients with overall goal setting, if someone comes to me and says, Hey, my goal is to lose 50 pounds. You can’t even wrap your head around that. It’s just so difficult. It takes so long. So let’s focus on, my goal is I wanna lose three pounds in the next two weeks.

That’s really doable. We can track that. We can really focus on that, and that is a goal that we can achieve most likely. So I think we need to be a little more realistic and not as rigid with our goal setting. And that’s the first key towards what things do we wanna change today, next month, the month after.

We don’t have to change everything overnight. That’s when we get into a point where we’re not gonna be able to sustain those habits.

[00:09:04] Gabby Reece: Do you, is this true even with alcohol? If, let’s say you’ve someone who’s been an alcoholic and then, there is this detox process. I think even when people have, issues with things like that, it’s even that you have to do in a very methodical and processed way. I think people don’t realize that’s true to even, I say that with exercise. I’m not gonna take you from sedentary in the couch and then now you’re gonna start training like a professional athlete. It’s a no-go. You’re gonna get hurt and all these things. So I think this philosophy is really important to drive home to people. It’s like incremental, realistic, small changes because like you said, anything we can adhere to, then we have a fighting chance. And I, so I really appreciate that.

In your book you specifically say. And it’s unfortunate ’cause we’re, we are motivated by aesthetic and numbers. You go, Hey, don’t focus on weight loss, focus on good health. And it’s funny how a lot of people are like yeah. Good health. It’s focus on vitality. They’re like, no, I want, I wanna focus on my waistline.

So do you guys have special language where you trick people or. Get them to buy in differently.

[00:10:09] Kristin Kirkpatrick: Most of my patients are female. A lot of them are perimenopausal, post-menopausal. That’s really the sweet spot of who I see. And I always say, and I use myself as an example, I always start the conversation with, I have three pairs of jeans that are in the corner of my closet, and I don’t get the scale out, but I do pull those jeans out when I’m trying to make better habits, and I then determine, okay, where am I in this process?

The jeans are a great barometer. It’s a great barometer for me as a clinician because it’s really an assessment of waist size as opposed to this obscure number on the scale, which is basically all of our stuff, right? That number. Is your fat, your muscle water. So that’s the way I start the conversation, especially with my female patients.

Let’s, you’ve got a pair of jeans back there in your closet somewhere. Pull them out, start putting them on once a week. This is gonna be a better assessment than some magical number that’s gonna create a false sense of happiness that you have to achieve and that you probably can’t stick to. So that’s the approach that I take.

[00:11:11] Gabby Reece: Can we get into, and I found this really interesting and I was like almost thinking of the different profiles. If the recalibrator, we can start with the preventer, but the recalibrator almost seems, I don’t wanna say dangerous, but they seem look it, I look good, we call that skinny fat in some places, whatever that is.

So can you guys, explain to me, ’cause I didn’t actually know about this, the four metabolic profiles.

[00:11:40] Kristin Kirkpatrick: Yeah. So we wanted to create an environment for patients to not focus so much on weight, but focus on what we felt was important. We did not think that BMI was an important factor. In fact, there’s been some studies showing that it’s not a great indicator of overall health.

So we came up with these metabolic profiles that are essentially in line with what is your weight size, and then what is that in combination with your metabolic numbers. So what’s your triglycerides your blood sugar, your lipid panel the recalibrator, you said it perfectly. This is your typical skinny fat.

So we have someone who is lean but unhealthy. So what does that unhealthy component mean? That means that their triglycerides might be elevated, perhaps their hemoglobin A-C, which is a three-month marker of blood sugar. Perhaps that’s elevated. So they can’t actually look at themselves and say, oh gosh, I’m not healthy.  The numbers prove and show a different story. So that is one profile. If you look at the preventer, that’s healthy and lean. So again, this book is meant towards people who want to prevent skinny liver. So your numbers are great, you’re lean. And then we have the opposite end of those. So we have someone who really needs assistance.

The regenerator, unhealthy un-lean. So waist size if you’re a female is over thirty-five. If you’re a male, it’s over 40 and you probably have at least two or three. Or more factors metabolically that are going on that put your health at risk, make you more prone to fatty liver fine tuner, healthy and non-lean.

Those are just the four ways of which we wanted people to look at themselves versus, okay, I’m this weight. My doctor told me I’m obese, or I’m morbidly obese. I felt awful when he said that word or she said that word. What does it mean for me and how I approach my overall metabolic health based on me as an individual?

So even though it’s a book, we try to be as personalized as possible, and this is our way of doing it.

[00:13:43] Dr. Ibrahim Hanouneh: If I may comment on one group, which is the lean and unhealthy quite honestly, we see there are some probably genetic component to that. And I and I make sure I reinforce that point with my patients.

It’s not all your fault. Some of us had unfortunately genetic makeup. That set the stage for metabolic syndrome, diabetes high blood pressure, high cholesterol, et cetera. But there are things that we can change, can’t change your genetics, but can change your lifestyle, get that diabetes under better control et cetera.

We see that specifically in certain cultures and the Asian population patients from India. We see it quite quite common where lean but but have metabolic syndrome they’re still at risk to develop fatty liver and they need to pay attention to those patients.

[00:14:30] Gabby Reece: Again I know you can’t, you don’t wanna overgeneralize. I’m just curious, do you think in those cultures where maybe they eat less so they’re not, I feel like in the US we really, it’s like our plates are huge and we’re just down to eat a ton. Where other cultures, Asian cultures Indian, you see there’s tr you know, culturally there, there’s a, they, there’s a modification, they’re not eating as much, but maybe if they’re high inflammatory foods, like a lot of rice or certain things that might that’s maybe why that’s happening.

[00:14:57] Dr. Ibrahim Hanouneh: Yes. Part on the short answer is yes. That’s certainly a factor. We’ve noticed increased consumption in rice in particular, like you mentioned in the Asian culture.

So less food, but probably the quality of food isn’t that great and it’s very rich in sugar and carbs. If you put that on the top of genetic makeup that set the stage for metabolic syndrome, fatty liver, I feel that’s play a significant component.

[00:15:21] Gabby Reece: Doc, I understand why you focused on the liver, but Kristen, what is it in, ’cause you’ll see people and you guys talk about the microbiome as well.

But this is really about using the liver and fatty liver disease as a litmus for health or making changes and things like that. What was it that you decided, okay, this is where I’m gonna focus on this book?

[00:15:44] Kristin Kirkpatrick: Really, my attention came to the fact that I had people that were coming to see me that referred to themselves as having a little bit of sugar problem.

And typically what we find is that they were slightly insulin resistant, so they weren’t at the point with their numbers that they were diagnosed as a type two diabetic. But they definitely have some challenges with insulin not being sensitive enough. I think what really prompted me to look at this were the people that came to me too late and they were already, let’s say 10, 15 years into fibrosis, some of the middle stages of fatty liver.

They had never looked at their liver as any aspect of what was going on within type two diabetes or insulin resistance. And now they came to me because they were scared and the fear factor was really setting in. So I really wanted to take the opportunity to reach people before we get to these stages.

The liver is resilient. It is. It will take a beating and it won’t even really give you symptoms until it’s well on its way towards more significant disease. So I didn’t want people to have to wait to that point. I didn’t wanna have to, people have people sit across from me because they were fearful.

Because their doctor figure out they have fatty liver, and now everything’s going haywire. Because it’s so preventative and because we can reverse it so significantly in those first few stages, I really wanted to take the chance to grab people before they get to those latter stages.

[00:17:12] Dr. Ibrahim Hanouneh: There is a stigma of liver disease in my practice. Patients comes in and what I have liver disease. I’ve never had significant alcohol. They’re almost embarrassed to say that they have liver disease. But I think this book, and I, that’s what I try to reinforce with my patient is no, wait a second.

This liver disease is a result of fatty liver. It has nothing to do with alcohol. Indeed, the most common cause of liver disease in the country and probably worldwide is fatty liver associated with metabolic syndrome, with diabetes diet that is rich in carbs, high blood pressure, high cholesterol, et cetera.

So that’s first point and the second point. This is a very common disease. Believe it or not, twenty-five percent of the U.S population affected by fatty liver. I I tell my patient, look around you. One out of four people you’re gonna see today have this condition. You’re not the only one.

This is a very common condition and that was one of the driver that drove me and Kristen to bring this epidemic, if you will, to the people attention.

[00:18:13] Kristin Kirkpatrick: It’s important to note as well that there are no pharmacological treatments for this. So I think really that was probably our largest motivator.

Let’s get something out there that can help people from a lifestyle perspective. ’cause right now we don’t have any other option.

[00:18:26] Gabby Reece: Dr. Ibrahim, I have to ask if you chose this field of medicine, because it is, you can pr it is, there’s so much you can do to take control and reverse it. It what, I’m just curious why you chose this aspect of medicine.

[00:18:41] Dr. Ibrahim Hanouneh: I’ve been always fascinated by the liver capacity to regenerate. Indeed, there is no other organ in the body, like in internal organ that regenerates other than the liver. And I will give you Gabby a quick example. We do a live donor liver transplant where you take a piece of a love of of the liver from a loved one, a piece of a liver, from loved one, and give it to a patient who need liver transplant.

If you scan the donor and the recipient just a few weeks after the surgery, the liver is back to the original sites. It’s almost like a science fiction and there is no other organ in the body that does this other than the liver. The mechanism is fully understood and there is a lot of research going behind that.

Hopefully one day we’ll be able to learn the mechanism of regeneration and that will change the face of medicine, quite honestly. And that’s the reason why fatty liver is treatable and reversible. So I’ve been always fascinated by the liver and the capacity of regeneration. And that’s technically what drive drove me there.

[00:19:41] Gabby Reece: Can you just spell out for people sort of some of the basic ways that the liver impacts, like when we have fatty liver, all the things that it can impact in our health, because I think sometimes we think of liver as something. Yes. Maybe we’ve learned if we’re eating tons of things without fiber that have sugar, it goes straight to the liver versus through the gut or alcohol.

But maybe I don’t though that we realize like how the liver then impacts our, the rest of our health.

[00:20:09] Dr. Ibrahim Hanouneh: Yeah, no, great question. I honestly, to put it in a simple way, I I like the analogy of the liver is a TSA gate. You go to the airport, you got to stop by the TSA before you gets in, before you get in.

And the same with the liver. Anything comes to your body has to stop. Filtered by the liver before it gets in. It’s really the first defense, if you will, before it gets into, before anything comes to the body. So when there is, when the liver is overwhelmed with fat or disease of any kind, the security gate is broken and some of the bad guys gonna get in, and when they build up in the system they will eventually cause a problem.

That’s why I always say fatty liver is not just a liver disease, it’s a multi-system disease. For example if you do have fatty liver, you probably at slightly increased risk at increased risk to develop heart attack and stroke. The most common cause of problems in patients with fatty liver is heart attack and stroke.

Patients with fatty liver are at risk to develop cancer not just liver cancer, but even cancer outside the liver. That speaks volume, that deliver is really impacting our entire body to your point.

[00:21:19] Gabby Reece: What about stress? Like you have people who are really busy and they’re high performing and they’re probably exercising…Let’s give it a perfect case scenario. They’re moving three, four times a week. They’re eating relatively healthy. I’m always curious about stress and what that, how that impacts parts of our body and our overall health. Do you ever see it directly on the liver as well?

We did talk about that briefly in our book about the impact that things like cortisol, which is that stress hormone and what really chronic stress can really provide.

Now, the other thing that stress impacts that is direct to the liver is increasing inflammatory processes. I was listening to a podcast recently that Deepak Chopra did, and I thought it was so fascinating what he said. He said that inflammation is the pandemic of our times. This is what we need to focus on.

And he related it back to trauma and stress. So he said anyone that is has experienced trauma, whether that’s acute or it’s trauma from any aspect is most likely to be inflamed. So we know that the release of cortisol, we know that chronic stress that is not managed through any means, it’s more likely to cause inflammation.

So as inflammation is the base of any disease, it has a direct impact on the liver and is especially harmful when the liver is already insulted by the replacement of healthy tissue with fat. So I think there’s like some kind of give and take that we can see that yes, inflammation will impact the liver and a fatty liver will be more likely to cause inflammation throughout the body.

But getting your stress under control, whether that means just meditation or taking a walk, everyone has, all of my patients have different ways of managing stress, can really have a nice direct impact, not just on the liver, but in terms of your eating habits as well.

[00:23:11] Gabby Reece: You talk about, I really appreciate it and for people listening inside the book, there’s also, ’cause people sometimes they need to be directed.

So you have lots of suggestions and, menus and food and meals and family plan as you mentioned earlier, like getting the family on board and even how to eat or plan for if you I’m curious, A lot of people, if they’re traveling for their work, this is really what kills them because it is hard.

Whether it’s knowing what oils they’re cooking the food in, or just sometimes you know, you’re by yourself maybe and you’re more lonely so you eat whatever versus like when you’re at home and you’re more on top of it. When you guys are seeing patients, are there real strategies that, that you give them about?

For me, I think it’s maybe if somebody already has best practices, they know how to deal with this. Let’s say you have somebody who’s really going, okay. I’m really gonna work at this. I’m gonna make a change here. This is hard for me and I’m gonna do it. How do you, what are the baby steps for them as they start?

[00:24:13] Kristin Kirkpatrick: Yeah, so I think baby steps, I think being relatable to your patient is always number one. Having the ability to check back in with me and not feeling intimidated that you can’t shoot an email or even a text shoot. So really just having that accountability. Think Dr. Hannon and I said it really well, that having that buddy system, getting someone to do this with you, we’ve seen that to be much more successful than just doing it on your own.

And I think that we minimize sometimes how great of an impact a baby step can have. So I’ll give you an example. I had a patient just a few weeks ago. This person does not like fruits and vegetables. Not willing to try anything. Just nothing, right? The being to his own admission, he had told me that his Parents gave him fries and nuggets when he was a kid and he never got out of this. We’re talking about like a high powered CEO who was having fries and nuggets at these business dinners, and I am not joking when I say that. So we started down this rabbit hole, if you will, about what? Is there any fruit that you like?

And he said, oh, I like apples. Like we’re just gonna focus on apples. And so that’s all we did. I said, okay, keep having the nuggets, the fries, we’re not there yet, but for the first few weeks, can we just get more apples to replace some of the snacks? That you’re having. So maybe to replace some of the pretzels, things like that.

And to your point, once he started having that, he was willing to look at some other options. So I think we go too hard, too fast, and we think it’s gonna be sustainable, and most of the time it’s not. So I think instead of looking at what my patients would refer to as deprivation, let’s look at what we can add in.

The more things we add in, it’s just going to be easier and more natural to take away some of those foods that are harming our health, rather than me saying, oh, those nuggets and fries are bad for you. Let’s just take that out.

[00:26:03] Dr. Ibrahim Hanouneh: Yeah. I give a quick example if I may from earlier today actually. I I had an agreement with a patient of mine with fatty liver is okay, let’s just change one thing and I really don’t want you to change anything else in your diet.

And that thing was regular soda. Let’s just stop drinking regular soda and forget about the rest of your diet, at least for now. And let’s just do that for the next that’s your challenge for January for for the rest of the month and see what happened. I bet you, I think, we are gonna see a significant improvement just by that one Change.

[00:26:35] Gabby Reece: I read some somewhere that the average American consumes 20% of, they drink 20% of their calories. Doc, maybe you could explain, because I think people don’t understand everyone. Okay, fruit, is it safe? Is it not safe? Could you just share, maybe explain, sugar with fiber. So a natural sugar with fiber, what happens in the body versus, like you said, a sugary soda, which that sugar I think goes straight to the liver.

Maybe you could, ’cause I think people don’t even, they don’t even realize what the gut does and how it works in our favor.

[00:27:11] Dr. Ibrahim Hanouneh: Sure. Yeah. The I would say two, just to make it simple. Two major problem with the processed sugar. Problem number one, like you said, Gabby, it will go straight into your system and the sugar goes up and when you have too much sugar on board your pancreas gonna produce insulin to bring it down.

So you’re gonna have a lot of insulin on board. Guess what? Insulin gonna encourage the liver to make fat and store fat, and that’s gonna lead eventually to fatty liver and insulin resistance. Insulin resistance will make you crave food more. So you go into a vicious cycle where you are eating carbs, producing too much insulin this will lead to fatty liver, make you crave more carbs, so you go into a vicious cycle that’s that’s problem number one.

Problem number two the processed sugar will change your microbiome, meaning the bacteria and the gut into a bad bacteria. Replace the good guys with bad guys. And those bad guys can cause a lot of problems. But one specific problem, believe it or not, the bad bacteria and the gut based on a recent study, it will produce alcohol and produce sugar.

And that’s technically part of the mechanism where the bad bacteria gonna lead to liver damage because it’s producing alcohol without drinking alcohol yourself and producing sugar without even eating sugar yourself. That’s part of the reason why every now and then I see someone in my clinic is I promise I’ve been following the right things and I’m unable to lose weight.

Because they have the bad bacteria that producing probably bad things, sugar and alcohol, and causing trouble. I can go on and on, but those are two quick explanations. Why the bad? What’s it why bad sugar? The processed sugar is different than the natural one.

[00:28:56] Gabby Reece: Kristin, you focus a lot on the microbiome in connection to all of this. I, it’s such a vast and limit, limitless, unlimited space. People be like good bacteria, bad, the bad guys, the good guys, healing the gut. All of these. I think for a lot of people it, it feels so foreign where would you start? How do you get patients? What practices, what foods, what things do you say, Hey, these are the baby steps towards getting that gut, that microbiome high functioning and why do you care about that?

[00:29:30] Kristin Kirkpatrick: I think most of my patients understand things like getting more fermented foods in their diet, things of that nature. When you were asking about fiber, that’s a huge component for me. And the way I refer to it with my patients is I ask them to only have foods that create competition for digestion.

So what that means is that if you’re going to have a piece of licorice, there’s zero competition. For anything to be digested other than that sugar, right? You have the licorice and your insulin goes up, blood sugar goes up. You have this whole array of symptoms that occur. You probably feel great and then you don’t feel great once blood sugar drops.

Competition for digestion occurs when fiber is attached to that food. So if we go back to the example of the apple, you have a bite of the apple, there’s fiber in the peel, there’s fiber in the meat, and now your body is saying, I got this sugar and this tastes great, but I got something else that I have to take down.

And I, I don’t know what to do with it. So the body can’t metabolize fiber, it can’t break it down. It doesn’t have the ability to do it. That whole process slows down. Blood sugar and it slows down how much insulin is needed. Everything slows down ’cause there’s competition for digestion. The fiber piece is so important for the microbiome because we look at things like prebiotics.

So prebiotics or non-digestible fibers that help those probiotics fly, thrive, flourish, give them good food. When we have very low fiber diets and we don’t have a lot of variety in our diet, we lack what’s called microbial diversity. So we don’t have a lot of diverse, different microorganisms, we just have a few, and those might work for us, but they may not.

So where I start is that competition for digestion and let’s get variety, right? So if I have someone come in and say, oh, my diet’s pretty good. Like I eat a whole bunch of kale and I love kale. What do you eat outside of kale? Kale’s, great. It’s sexy, it’s trending, it’s great. What do you like outside of kale?

And if the question is I don’t think about it really that much, let’s now look at, okay, what other variety of foods can you get? What other colors can you get? How about some spinach? How about some broccoli? How about some Brussels sprouts? So getting that variety can lead to microbial diversity.

Microbial diversity, we know helps in healing the overall microbiome.

[00:31:51] Gabby Reece: Do you ever like for, ’cause a lot of people, it is funny when you get people who are like, I don’t eat that. I don’t eat vegetables. Do you ever use supplementation like a powdered greens or any of that? And I know it’s different because it is powdered, it’s, it doesn’t have the same kind of fiber and all those things.

How do you guys feel about that. That is a way to support people’s health.

[00:32:10] Kristin Kirkpatrick: Yeah. I think that it can be a great way to get some nutrient density in while someone is trying to increase some of the variety in their diet. I think what really matters, and this is why I really want my patients to bring these things physically to me, is looking at the ingredients, right?

So finding things that have something as close to nature as possible and really trying to find ones that don’t have a lot of additional supplementation. So the greens might be a great idea, but then when you have all these other vitamins coming in with it, or potentially herbs that could interact with already medications that they’re on, then it can become a little bit more problematic.

So the more true to nature we have, the better the approach. I’m not a huge fan of having it as a long-term solution. I think that it’s a great thing that we can focus on while we are really trying to get more, produce, more fresh foods into our diet.

[00:33:06] Gabby Reece: Dr. Ibrahim, I’m curious, another really confusing thing for a lot of people is, natural sugars or, it’s oh, Stevia, it’s good, it’s bad.

Could, would you, could you share, which things still impact the liver? Because there’s, they’re getting quite fancy on where it’s oh, it doesn’t impact your, blood sugar. But somehow I would be interested to know, does it still impact the liver?

[00:33:37] Dr. Ibrahim Hanouneh: The main things would be changing the microbiome.

Be honest with you. With that kind of sugar. And that changes in microbiome will eventually lead, like we mentioned to liver damage. Because the bad microbiome, the bad bacteria, the bad guy is gonna produce some substance, which which affect the liver. I tell I tell my patients everything in moderation.

The I would always go natural. Natural is the way to go when it gets to sugar and pretty much everything else but if you really like your Stevia, probably okay, but in moderation and because it will eventually lead to changes in your microbiome and those changes can cause damage to your liver or can make the recovery from liver disease difficult or possibly or maybe impossible.

[00:34:23] Gabby Reece: So when we say natural, you’re saying real honey. Brown sugar. Like what? Because again, people, they’re confused and overwhelmed with not only a ton of options. My favorite is like sugar, alcohol. It’s are you guys kidding me? I, when you like, you mean whatever is in the food and go for that. But if someone goes, Hey, I wanna put a little in something, do you prefer a certain type?

[00:34:49] Dr. Ibrahim Hanouneh: I would I would say, when I say natural the natural sugar in food, fruits and vegetables, it’s a perfect example. That would be okay. But if you’d like to add sugar every now and then I think that would be fine.

We we actually in our book we think away from the keto diet we don’t like to say no sugar or, number one, because it’s very difficult to stick with with very low sugar. And number two, it turns out if you stick with keto diet or low sugar on the long run, that may cause problem.

So if you do, if you the technically the diet recommendations we have in the book, were mostly moderate carbs intake. We’re not against adding sugar every now and then to your diet or having a chocolate or, a pie every now and then. I think that will be fine.

Like we said, everything in moderation. We like the moderate carbs intake. We don’t like too low, we don’t like too much.

[00:35:45] Gabby Reece: It’s almost like if people get that lifestyle component right, then they’re not gonna get killed by a birthday cake night or something. The way, if someone’s already on this threshold where every little thing they do irritates their body versus, you’re working out, you’re eating overall.

Really that okay, these things like a chocolate or a piece of cake isn’t gonna kill you. I’m curious about the keto component. If someone goes too long on keto are you, what are you seeing inflammation, or what are you seeing that shows up that it can be damaging?

[00:36:16] Kristin Kirkpatrick: We looked at some of the data on keto and it was really the sustainability of keto.

So I think we definitely need, we need more research on really, if you’re staying on keto for over 18 months to 24 months, what does that look like? There are some really positive aspects of keto long-term. There’s no doubt about that. I have plenty of patients on it that have completely helped their cholesterol become normal without pharmacological approaches.

What we were seeing is it’s hard to stick with. So our whole concept was let’s try and find things. Dr. Hannanay said it perfectly, find the diet that you like, but also have seems to happen to be a little bit more nutrient dense than the diet that you’re trying to improve. So it’s the sustainability of keto that was a little concerning for us, that most people can stick with it three to six months, but then they tend to go back based on the data to their old habits.

[00:37:14] Gabby Reece: What are the things that you’re saying, hey, to people if you’re gonna have it on your plate. Vegetables obviously, or carbohydrates, but maybe you could just share some of your favorites and you really break this down so easily in the book when you’re leading people to carbs. ’cause I think you have a group of people that think carbs is bread and bagels.

And then you have another group that goes, no, that’s rice. And then you have another group that realizes like actually vegetables and sweet potatoes. So where do you guys educate people on. When you say carbs, yeah.

[00:37:46] Kristin Kirkpatrick: We really took the approach of looking at digestible carbs or net carbs, and that is the amount of carbohydrate that the body is actually going to digest, metabolize, etc.

After we deduct certain other compounds such as fiber. So because fiber is not digestible, let’s just say for even numbers, you have a pasta that has 10 grams of carbohydrates, five of which are fiber. Only five grams of carbohydrate will actually be digested because the body can’t digest the fiber. So we did take a net carb approach.

The regenerator is going to have a different carb approach than the preventer, for example. But what we’re really focusing on at the high level is complex carbohydrates. So looking at, okay, let’s look at having more whole grains. If you have white rice, let’s just make the swap for brown rice. But depending on what your metabolic type is, that’s when we would be more specific on amount.

So someone who is insulin resistant or type two diabetic. And has all these other components going on in health, they might do really well with a lower carb approach versus a moderate carb approach, which is about forty-five percent of total calories for someone who’s just the preventer just wants to notices that they’re getting older, perhaps they’re menopausal.

They’re noticing that three-month marker of blood sugar is just creeping up a little bit. Maybe I want to taper down and have a little less carbs, but still have a lot of nutrient density. So we’re talking complex carbs, obviously cruciferous vegetables, which are very high and fiber. We’re talking about things like nuts and seeds, which nuts and seeds can have some carbohydrate in them, but.

What we’re trying to do is not become people that are fixated or dare I say it, obsessed with the carb count, but rather looking at what’s the nutrient density and how much carbohydrate is my body going to be forced to process based on my other health indicators?

[00:39:49] Gabby Reece: Doc, I can’t imagine that you thought when you were in medical school that you’re gonna be sitting and talking quite so much and breaking it down about the nutrition aspect.

Then on top of it, what about the movement component? What’s the conversation around that? Because I feel I could be wrong, but I feel like the food is the hardest because it’s something we do for a number of reasons besides being hungry several times a day. I almost feel like once people can get into a movement pattern, it’s easy.

But can you guys share the role of exercise in helping support a healthy liver?

[00:40:27] Dr. Ibrahim Hanouneh: One, one thing I reinforce with my patient about exercise, we are busy and I understand you don’t have time to a, go to the gym every day, but based on a recent study from Australia showed that all you need is 15 to 20 minutes every other day.

And and the study actually suggests that interval training would be probably better. Meaning if you can if your physical status allows you a jump in on treadmill or a standing bike. And, go interval training, kill yourself for a minute or so if you can, and then slow down and go up again and slow down.

And, all of us have 15 minutes every other day or three days a week. And it turns out that’s technically the kind of exercise that you need to burn the fat in your liver. Certainly exercise is very useful. It’s a wonderful component to diet but I reinforce the fact that it’s not exercise alone is not enough.

You got to combine exercise with healthy diet. Myself actually, I try when I cheat with my diet, every now and then it is okay, I better go to the gym to burn. You know what I just ate. So that’s that’s my two sentence on exercise.

[00:41:34] Kristin Kirkpatrick: There’s some very interesting data that we’ve seen over the past decade looking at the benefits of blood sugar management and even looking at just just a basic walk after a meal. So we’ve seen some studies in diabetic patients where you have a meal you take a walk after as opposed to sitting on the couch and watching the evening news and what that does to your post meal blood sugar status.

And it’s really quite fascinating. So if our goal is really to look at what is the blood sugar, how can we manage it a little more, how can we make this create this state of homeostasis? Then maybe even just walking, right? We don’t have to become what you had said earlier. We don’t have to become the professional athletes.

We can just take a walk. And so I think that’s the other component. The data is not very strong. That exercise does a huge amount of benefit to weight loss, but it’s very strong in terms of weight loss, maintenance. So at some point you have to bring it in for chronic disease risk, for the reduction of certain cancers.

You might as well do it now, but it doesn’t have to be that you’re going to run a marathon. I tell my patients, just be more vertical throughout the day. Just be more vertical, walk a little bit more, and that will go a really a far way.

[00:42:50] Dr. Ibrahim Hanouneh: And on that note, I I tell my patient not to discourage themselves if they’re not losing weight.

With, because exercise like Kristen said, can be useful. Even if you don’t lose weight maybe you are replacing, the the fat with muscles and that’s why you’re not losing weight. Yeah, and this has been proven actually in really in, in scientific research that patients with fatty liver benefit from exercise regardless whether they lose weight or not.

[00:43:16] Gabby Reece: And it’s funny too because I think when you train a lot, people have to realize sometimes you eat a little more if you’re more hungry, whatever. But also I think, I feel at times you, you can get more watery. Your muscles can get watery. I think there’s a, we get, especially women, and you said that earlier, Kristen, we get so afraid of, we’re so fixated on numbers.

And I think that’s a dangerous place. So if you, what if you have a patient who comes in and they really, they’re behind the eight ball. Like it, it’s that place where the body, it’s not giving you, it’s not working the way it’s supposed to. So everything is harder, right? Getting the benefits from eating or moving, it’s harder.

All of these things. Is there a way, do you make it a little more drastic or turn or dialed in for them for a extended period of time to try to get them into momentum?

[00:44:07] Kristin Kirkpatrick: I think sometimes it’s about looking at their dietary pattern and trying to pinpoint what could be certain things that they might not be recognizing as holding them back.

And I’ll give a great example, and I saw this a lot during the pandemic. I had all of these patients come to me again, mostly female, and they would say, gosh, I’m doing everything to lose weight. It’s not working. And at the end of it all, I realized that it was that glass of red wine every night that really was killing it.

That is an example of, okay, let’s look at the dietary pattern. And many of these women would say I only have one glass. And that falls be behind the American Heart Association guidelines, right? One glass a day. But that one glass is five ounces, so most people are not measuring. So it’s usually more.

Even though that is the recommendation and there’s some argument whether or not that’s too much. And I would think it is too much.

[00:45:03] Gabby Reece: I’ve heard like a thimble two ounces, which me almost sounds like just take a shot of vinegar, which I don’t know, it’s and they really, when you see what’s recommended,

[00:45:11] Kristin Kirkpatrick: And we have such there are so many great non-alcoholic like elixirs and things like that right now that is just this is, I actually see now that people have become a lot more laser focused on what some of these things are with alcohol and some of the challenges. Now I’m getting questions.

Do you know any of these brands? Are there, is there a brand you love? Is there one that has less sugar than others? So it’s interesting how the conversation has shifted, but that’s just one example. Another example could be that people are simply eating to fullness and not eating until they are no longer hungry.

So I don’t really believe in portion control, but I do believe in listening to our body and so that, that could be another thing. Sometimes it’s just that we’re eating too much. We’re over-fueling and we’re not stopping. Once we feel that hunger is gone, we’re stopping once we feel full. And so we’ve over-fueled.

So even just cutting back on that sometimes and that doesn’t happen overnight, can be a trick to really get people to start seeing some change.

[00:46:12] Gabby Reece: What about hydration in all of this? How, is there a way that sort of diluting things or making sure you’re hydrated is, I know it’s great for your body and all of these things, but is there some role that plays with the health of your liver?

[00:46:29] Dr. Ibrahim Hanouneh: Yeah, certainly dehydration does not do any good for your liver and for your own body. So hydration, I. And how do you hydrate yourself? Stay away from the the sugary fluids, if you will. And and water, probably natural water is the way to go.

And but on that note, I can bring one things that will be beneficial to the liver and it may help a little bit which would be coffee. Coffee actually. People ask all the time about what can I take to help my liver, herb supplements water, hydration, etc.

But really the main supplements, if you will, that has been proven over and over to be beneficial to the liver would be coffee black coffee ideally black. Don’t mix it with anything if you can. And and two cups of coffee a day. You don’t wanna overdo it because it may drive the blood pressure and the sleep and stress on other things, obviously out of control.

Two cups a day of coffee. That’s probably the the way to go to help your liver prevent fatty liver disease and even help reverse fatty liver disease when it’s present.

[00:47:31] Kristin Kirkpatrick: And we have some studies showing that dehydration sometimes can be confused for hunger. So even just staying hydrated can be really beneficial.

And if we’re trying to control our intake throughout the day, dehydration really, sometimes my patients will say, oh gosh, I thought I was hungry, but I wasn’t. I was just dehydrated. So it’s another reason why it’s important amongst all the other reasons why hydration is so important.

[00:47:54] Gabby Reece: Are there, I you did say the coffee, but are there any supplements that you go, Hey, these are really, they do a lot of good lovin on your liver.

[00:48:04] Dr. Ibrahim Hanouneh: Other supplements would be vitamin E. There are several studies on the use of Vitamin E in fatty liver. It turns out it decreases fat in the liver and it decreases inflammation as well. It’s antioxidant so it’s not surprising to to do good for the liver. From that end we don’t like to take vitamin E long-term.

We like to take it short-term because it turns out long-term use of vitamin E can potentially lead to long-term side effect, but short-term use would be just fine. Those are the two main supplements in my practice that has been shown to be beneficial for fatty liver.

[00:48:40] Kristin Kirkpatrick: I typically will recommend Omega-III fatty acids. Most of the liver studies do focus on the marine form of DHA and EPA. ALA is great as well. So there’s, if you can look at algae oil or some vegan versions of that, if you’re vegan, it’s fine. But DHA and EPA have been found to help reduce fibrosis in the liver. If you had non-alcoholic fatty liver disease, because fibrosis is in that middle stage where you’re starting to get inflammation, you’re starting to get the replacement of healthy liver tissue.

Omega-III could have a great impact there, especially if you’re someone who is not eating fatty wild fish. I think the recommendation is two and a half days per week. I don’t know where the half comes from, but that’s the official recommendation. But if you’re not eating enough fish, definitely an Omega-three fatty acid supplement.

[00:49:32] Dr. Ibrahim Hanouneh: And on, on that note it might be worth mentioning what it’s not. What supplements not good for the liver or not beneficial to the liver? I see it in my practice all the time. Patients ask about milk thistle and milk thistle and deliver. I don’t think milk thistle is bad for the liver.

I just don’t think it’s, it does any good. It’s been studied in management of fatty liver disease and really didn’t do anything. So that’s one very popular if you will supplement out there that I think, it’s overused or overestimated. And then there are a lot of supplements and herbs and things purchased online that detox your liver, et cetera.

I would say they’re not scientifically proven. Every now and then I do see liver damage from those supplements. So be careful out there. Just stick with the stuff that are really, has been studied and proven and regulated. I wouldn’t just go and purchase things that are unregulated because they may cause more harm than good.

[00:50:28] Gabby Reece: Kristin, you probably hear this, more often the people will do cleanses, and then it’s like the eighth day and you’re gonna do a liver flush. A half a cup of olive oil and grapefruit juice or whatever, and then lay on that side and suffer through the night. I’m just curious.

[00:50:44] Gabby Reece: Let’s say someone things are healthy, everything’s good, and people are, do what, trends and things like that. They come and they go. How do you, when that shows up, how do you feel about that? Or the best way to do that or not do that?

[00:50:57] Kristin Kirkpatrick: So because we’re always. Really looking to follow the science.

We don’t really have any data. Definitely not strong data, long-term data, any randomized control trials that show that some of these liver cleanses actually do anything. So really at best, it’s going to be neutral. There will be no effect whatsoever. At worst, you could have some electrolyte imbalances, you could have some damage, especially if you’re doing on a more frequent basis.

The liver is in the body for a reason. We didn’t talk about it. We’ve talked a lot about sugar and fats and everything like that, but the liver is, and Dr. Hannanay said it great when he talked about being the TSA. It is the place that detoxifies everything that comes in that needs detoxification.

So it’s not just alcohol, that’s a toxin. We have toxins coming into our body all the time, and the liver is responsible for breaking that down. So as long as we’re taking care of the liver. We don’t need a liver cleanse to boost that to, to help that. And we don’t have the science supporting it.

So if we don’t have the science, I would rather my patient take the a hundred dollars or more that they spent on the liver cleanse and head to the grocery store and get some great vegetables, right? That’s a better idea in my head and a better investment in health.

[00:52:18] Gabby Reece: Again, I am somebody who has some distance. I’ve been in this a really long time, but I try to look at it through the lens of somebody who’s trying to start best practices and I think, oh my God they’re coming at you not only with, okay, eat like this, not you, but the, the idea of being healthy, but it’s oh, but don’t eat that because that’s not organic.

And like corn is, the most modified food and now we have, everything’s GMO or there’s plastics in the water and it’s all these things that I think they almost, I don’t wanna say they paralyze people, but. Instead of step by step like what you’re talking about, I feel like they go, oh, why bother?

It’s all, not gonna work. Anyway. I’m curious about two things. One is, do you direct people towards Hey, listen, it does matter what vegetables you’re eating. Try to get organic. Because again, less, maybe less detoxing if things are sprayed or what have you. I wonder if you have to go that far into the conversation with people.

[00:53:16] Kristin Kirkpatrick: We do go into the Dirty Dozen and the Clean 15, which is from the environmental working group. We do not go any further than that. Goes back to you can get a really great high sugar, refined grain vegan cookie at the grocery store. You can also get one that’s made organically, right?

So in, in our world. We recognize, and in our patients, we recognize that the quest for organics, if you wanna go organic, it’s great. A lot of our patients don’t have that luxury. And so really it’s better that they simply eat vegetables versus I’m not gonna have a vegetable if it’s not organic. And I think the dirty Dozen does a great job with that.

So things like apples, strawberries grapes, things that are on it every single year. If you can get organic, that might be beneficial because of the high amount of pesticides that these foods have. But if you can’t, it’s not gonna make or break it. It’s better for you to have that non-organic apple than it is to never have a fruit.

So I think we need to look at it a little bit more high level, give ourselves a break. I always joke that if you study kale for 30 years, one study’s gonna come out and say it’s gonna kill you, right? So that’s it’s a joke, but the point is we can seek out the study that we’re trying to look for and really not know if it’s a quality piece of data.

And I think that’s what a lot of patients do is I saw this or I saw this online. It’s really about getting back to the basics. It know Michael Pollan defined food as something that comes from nature is fed from nature and will eventually rot. And quite frankly, that’s probably the best approach to how we should look at our dietary pattern.

[00:54:55] Gabby Reece: You hear about like certain cooking oils, especially ones that have been heated up and cooled back down. Like people go to restaurants and they have, fries or something in oils that have, the temperature’s been up and down. Never mind if it’s canola or other vegetable. Is there, do you have a particular feeling about the types of oils that you would like to direct people towards, whether they’re eat, putting in salad dressing or eating themselves or, using to cook.

[00:55:22] Dr. Ibrahim Hanouneh: Yes, olive oil, quite honestly has been shown to be beneficial to the liver. And that’s part of the reason why the Mediterranean diet. It is probably one of the best diet in general for cardiac health and certainly for liver health. Studies from the New England Journal of Medicine, which is one of the most prestigious medical journal we have out there studied the Mediterranean diet in terms of cardiovascular events, and it showed that it decreased the incidence of cardiovascular events, heart attack, and stroke on the long term.

And the same happened with fatty liver disease. So to answer your questions that, that brings me into olives and olive oil probably bit the the the way to go when it gets into oil.

[00:56:04] Gabby Reece: Can we end this? First of all, I’m also curious because both of you seem to be, you know so much already, but it seems like you continue to learn and pay attention.

I’m just curious where you both individually go to, to, see what’s going on and what’s out there and how you both continue to keep evolving and learning.

[00:56:29] Kristin Kirkpatrick: So I think, I don’t know if Dr. Hanouneh would say this, we’re both products of the Cleveland Clinic, I feel like most of the time when we weren’t with patients, we were looking at journal articles, we were looking at what was in the data, what were the studies that were coming out on any given week.

And I continue to do that. If I’m presenting I want to start off with, Hey, this study came out today and here’s the breakdown of what it looked like and here’s the interpretation that I can provide that, that might help. So I think the data is always the most important aspect. I think we also always have to have our eyes open to misinformation that’s being provided.

Because a lot of times I don’t wanna be the first person to hear about it when a patient brings it up to me, Hey, this trend is going on, or, I heard you should drink this juice and this is great. So just being aware of all of those things that, that really are touching our patients’ lives and trying to make them help them to make the best decision that makes sense for them without having them feel that they’re being deprived or told how to eat.

[00:57:31] Dr. Ibrahim Hanouneh: I echo what Kristin said. I, I’m also actively involved in research for fatty liver. Both on the diet side and the pharmacological side to treat fatty liver disease. But above all, quite honestly, I learned the most from my patients. I feel every day that is like they teach me something.

And that’s priceless.

[00:57:51] Gabby Reece: I think I hear that a lot, that the patients, the openness exchange back and forth. I, you said something earlier about what, how we learned to eat as children. And I’ve had a lot of people say to me like, oh, I just, it’s my genetics. And it’s no, you inherit you inherited the genetics, but you also inherited the lifestyle.

And I think it’s reminding people that our genetics are fine. We just have to hit other levers and that we have, people, I think they don’t think that they could possibly either be that manage their weight that way or, be built that way. Could you guys in, in wrapping this up, share if it comes to top of mind just a story of success that really has inspired you?

[00:58:32] Kristin Kirkpatrick: Yeah, so I think when you were mentioning genetics, I was thinking of a patient who I was doing a nutrigenomics test. With, so we Cleveland clinic and Integrative medicine, we have Neutrogenomics testing and we do a lot of these tests. So that’s just breaking down what are some of the genes forty-five to 70 genes we might go through within one test that are related to lifestyle.

So someone came in and there was a lot of genetics involved in heart health, heart disease, etc. And I had said your genetics are your predisposition but not your destiny. So really the goal is trying to determine how we turn a gene on or off. So I think from that perspective, and this person had type two diabetes, but did not have fatty liver.

I think from that perspective, what we looked at were where are your genetics really doing well? Where is it great? And let’s really focus on that, whether it was the genes associated with physical activity or nutrient metabolism. And then what are the very small pieces we can look at from the cardiac side that we can maybe make some small changes.

And that really was, I think this theory that this is your predisposition, not your destiny. You don’t have to become your mom or your dad who had the heart attack at forty-five. You’re more likely than someone who doesn’t have those genetics, but it doesn’t mean it’s going to happen.

So what can you do? What can you take control of where you can control that within yourself and try and prevent what you saw come before you?

[01:00:02] Dr. Ibrahim Hanouneh: I can think of story just happened recently where a patient of mine had, fatty liver disease and unfortunately was diagnosed at later stage where she already had advanced liver disease and and wasn’t doing too good.

And before she’s gone she asked her son to promise her one thing, which is would take care of himself and get screened for these conditions early on. And he came to see me in the clinic. He is you took care of my mom, this bad person, and, and I had a promise to her to come and take care of this.

And we talked about genetic makeup. They probably have fatty liver runs in the family. We don’t have control over that, but like we said earlier, we do have control of how to turn off and turn on those genes. The lifestyle changes could turn those genes off.

And I think he’s on the track to get things fixed and hopefully not end up with advanced liver disease.

[01:00:54] Gabby Reece: Is there any kind of final invitation or something I missed that feels really that’s on either one of your minds that it feels important to remind people or invite people?

[01:01:06] Kristin Kirkpatrick: Yeah I think when we think about this book, or we just think about our own practices and who we see on a day-to-Day basis, I think it’s most people will assume I don’t have anything wrong with my liver, so I don’t need this book, but.

The nomenclature the way that the liver organizations refer to non-alcoholic, non-alcoholic fatty liver disease has changed in the past six months. It’s now referred to as MAFLD, which is metabolic associated non-alcoholic fatty liver disease. Anyone that is really struggling with any component of metabolic health whether that be high triglycerides or an elevated waist circumference, whatever that is, this is maybe an approach that they want to consider.

So I think a lot of times when we think about the liver and what we’re trying to communicate, we never wanna be doom and gloom. That’s why I said it’s resilient. It’s really gonna work for you if you work for it. But I think this can impact a lot of people just from the fact that a lot of people have diabetes or insulin resistance, et cetera.

This can be really a really proactive way to prevent ever having to see someone like Dr. Hanouneh in his office because you’ve gotten to that point.

[01:02:12] Dr. Ibrahim Hanouneh: Yeah, no, I I guess the big teaching point is that this is a very, not to be alarmist, but this is really common problem. This is a fact that 25% of the world has fatty liver disease.

That’s obviously a huge problem. But the but this problem is exacerbated by, this is a silent disease. It does not really have symptoms until it’s too late in the game, and we don’t wanna wait too late. And that’s where it comes into screening. If of someone loved, one, family member, friends, family with type two diabetes, high blood pressure, high cholesterol, overweight, unhealthy lifestyle make sure they get screened for fatty liver when they see their physician doing annual physical physician or dietician during annual physical.

[01:02:57] Gabby Reece: That’s, I feel, the big teaching point and Oh, even kids now can suffer from fatty liver. Correct? Yes. Yeah. So I’m just saying, sometimes I think, oh, it’s oh, 30, 40, 50. And just remember people, especially depending on their nutrition, I think, just to remind people. So I really appreciate your time and I appreciate that you guys collaborated again, the book is Regenerative Health.

I think for me, what I also took away from, besides tons of information spelled out was this, I, there’s a, the notion of regenerative, both of you are approaching this from a really proactive and hopeful point of view, which I feel like. Is the only way that it keeps us motivated. I know everyone, sometimes people are afraid and they get going, but I think of this idea of no, you can really improve this is really powerful.

[01:03:43] Gabby Reece: So thank you and I know it’s a lot of work and you already are doing a ton of other things, so thank you for doing this and putting it together for us.

[01:03:51] Dr. Ibrahim Hanouneh:  Thank you very much for the opportunity. Yeah, we are honored to be with you today.

[01:03:59] Gabby Reece: Thank you for listening to this week’s episode.

About Kristin Kirkpatrick MS, RDN \

Kristin Kirkpatrick is the President of KAK, Consulting, LLC, a dietitian at the Cleveland Clinic Dept of Department of Wellness & Preventive Medicine in Cleveland, Ohio, and a Senior Fellow at the Meadows Behavioral Healthcare in Wickenburg, Arizona. She is a best-selling author, an experienced presenter, and an award-winning Dietitian. Kristin is a contributing writer for, Eating Well Magazine, Costco Connection, and Cleveland Clinic Essentials and has appeared on both local and national shows such as the TODAY show, NBC Nightly News, Fox Business, Bloomberg TV, and the Dr. Oz show. Kristin is also a Nutrition Expert with the NBC affiliate for Denver, Colorado.



About Dr. Ibrahim Hanouneh

Dr. Ibrahim Hanouneh completed his internal medicine residency and gastroenterology and hepatology fellowship training at the Cleveland Clinic. Dr. Hanouneh served as an associate staff at the Cleveland Clinic in Cleveland, Ohio before he moved to Minnesota to join MNGI Digestive Health in 2015. At the present time, Dr. Hanouneh serves at the Board of Directors of MNGI Digestive Health. Dr. Hanouneh has spent a great deal of time in liver disease. He has a passion for studies related to fatty liver. He co-authored the “Regenerative Health” book, and the “Skinny Liver” book. He has presented at several national and international meetings and has been an author on over seventy papers as well as numerous abstracts.