Dhru Purohit Show - The True Cause of Fatty Liver Disease and the Top Dietary and Lifestyle Habits to Address It with Kristin Kirkpatrick & Dr. Ibrahim Hanouneh

Episode Date: January 17, 2024

This episode is brought to you by Bioptimizers and Sweetgreen.  When discussing chronic disease and crucial organs, we don’t always think about the role the liver plays in our body. Yet, the liver has a role in every metabolic process in the body, including ensuring our blood sugar levels are stable or ensuring that amino acids are converted into fuel.  Today on The Dhru Purohit Podcast, Dhru sits down with Kristin Kirkpatrick & Dr. Ibrahim Hanouneh to shed light on an epidemic affecting one in four people: non-alcoholic fatty liver disease. Dr. Hanouneh and Kristin share the biggest risk factors that lead to fatty liver disease including, metabolic dysfunction, diabetes, and insulin resistance. Dr. Hanouneh and Kristin discuss the rising prevalence of non-alcoholic fatty liver disease, emphasizing major risk factors such as metabolic dysfunction, diabetes, and insulin resistance. They also explore how factors like the consumption of ultra-processed foods, sugar, and a sedentary lifestyle contribute to the increase in fatty liver cases.  Despite these challenges, there is hope. Dr. Hanouneh and Kristin share that fatty liver is a lifestyle disease, and changes to eating and lifestyle habits can effectively treat most cases of this condition.  Dr. Ibrahim Hanouneh, MD, is a gastroenterologist and hepatologist specializing in liver disease. Kristin Kirkpatrick, MS, RDN, is a celebrated author, speaker, and accomplished dietitian with over 25 years in the field. Teaming up with Dr. Ibrahim Hanouneh, Kristin co-authored the bestselling book Skinny Liver in 2017, and their upcoming release is called Regenerative Health.  In this episode, Dhru, Kristin, and Dr. Hanouneh dive into (audio version / Apple Subscriber version): The top warning signs that you have fatty liver disease (2:36 / 2:36 ) What leads to fatty liver and the major components of fatty liver disease (4:21 / 4:21)  The relationship between fatty liver disease and chronic inflammation (20:08 / 18:45) What has caused the increase in rates of fatty liver disease (25:14 / 23:45)  How to treat and reverse fatty liver disease (44:28  / 41:31)  Four metabolic types and the importance of identifying your type for risk of fatty liver (51:44 / 48:30 )  The key tests to measure your risk of fatty liver disease (1:12:17 / 1:08:40)  Factors beyond your control that can contribute to fatty liver disease (1:16:27 / 1:12:30)  Alcohol and its role in fatty liver disease (1:25:40  / 1:22:40) Gut health and fiber consumption and the impact on the liver (1:31:25 / 1:28:10) 12 Liver-friendly foods to incorporate into your diet (1:36:57 / 1:33:43)  Supplements that can support liver health (1:48:50 / 1:45:30)  Also mentioned in this episode: Regenerative Health Book Start the New Year off right and dial in on your sleep. Go to bioptimizers.com/dhru now and enter promo code DHRU10 to get 10% off any order. Find out more about Sweetgreen and their newest protein plates at www.sweetgreen.com. New Users of the sweet green app can use the code "Dhru5" for $5 off.  Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit megaphone.fm/adchoices

insulin resistance, anything where we are overloaded, as we typically are in the American diet with sugar with refined carbohydrates. This is what is really leading to the storage of fat within the liver that then replaces healthy liver tissue. Hi everyone, Drew Prode here, and today we're chatting with Kristen Kerpatrick and Dr. Ibrahim Hanone. And they're here to talk about a silent epidemic that is impacting many, many people and that silent epidemic is fatty liver disease which by the way most people who have it actually don't know they have it that's why this episode is so important we're going to be talking about what fatty liver disease is what causes it and most importantly what to do to potentially

reverse it through diet and lifestyle now a little bit more about today's guest dr ibrahim hanone is a gastroenterologist and hepatologist specializing in liver disease He completed his internal medicine, residency, and gastroenterology and transplant hepatology fellowship at the Cleveland Clinic. He has served as the chief gastroenterology fellow and associate staff at the Cleveland Clinic and later contributed his expertise to Minnesota Gastroenterology and Mayo Clinic in Minnesota. Kristen Kerpatrick is a celebrated author, speaker, an accomplished dietitian with over 25 years in the field, currently serving as a dietitian at the esteemed

Cleveland Clinic's Department of Wellness and Preventative Medicine. Kristen is also a senior fellow at Meadows Behavioral Healthcare in Arizona. Together, Kristen and Dr. Hanoneh co-authored the best-selling book Skinny Lever in 2017. Their upcoming book is titled Regenerative Health. It's all about fatty liver and it's the focus of today's conversation. Kristen, Ibrahim, welcome to the podcast. A pleasure to have you here. I want to jump right in.

Something mind-blowing that I've learned from your work over the years is that most people that have fatty liver disease don't actually know that they have it. That's why the two of you call this a silent epidemic. Now, before we get into what it is, I'd love to start off with what are some of the biggest warning signs for somebody listening today, knowing that the vast majority of people that have fatty liver disease don't know they have it, what are some of the top warning signs that somebody listening today might be struggling with it or is on their way to struggling with it. Kristen, do you want to jump in first?

Yeah, let me jump in. I would love to. And thank you for having us today. Drew, we're so honored and privileged to be on the show. You know, I think sometimes when I think about what my patients come to me with, it oftentimes is fatigue. And like I always say, who doesn't have fatigue? So fatigue can mask a lot of different other conditions. But a lot of times people will come to me and say, just really feeling down. I'm really feeling not myself. And it's only after they go see their physician that they find out maybe their liver enzymes are elevated, things like that, that we might start to pinpoint it.

And I think the reason for that, and Dr. Hannanay can talk a lot better to this point, is that really the liver is so resilient. It speaks to its resilience. And it's not going to give you a lot of kind of the like hard signs in the first few stages. You can go a long time without feeling some of the more aggressive approaches to, I'm feeling this and I must have fatty liver. So for me as a dietitian, a lot of times my patients are coming in saying, I'm just tired. Maybe my skin's not great. I don't know what's going on. Maybe nothing, but what do you think? And then once we delve a little bit deeper,

we can see that they're at risk for non-alcoholic fatty liver disease. Dr. Hannanay, when somebody comes to you, especially at the later stages, and we're going to break down all the stages, is your top foods to support and feed the liver. And also the most fascinating thing that I saw in the book, which is the four metabolic types, you know, the people listening today, they're going to want to understand these four metabolic types and which one they are so that they know how to support their liver.

But when somebody comes to you in the later stages, what are some of those warning signs that they've been struggling and they're dealing with fatty liver disease? Yeah, thank you very much for having us. Fatty liver disease, like you indicated, it's epidemic. You know, it's very common. You look around you, you look at your family members. One out of four people have fatty liver disease.

Just think about that for a second. One out of four people you're going to meet today have fatty liver disease. This is very common. The problem, this is a silent disease until too late in the game, until you have, God forbid, liver cirrhosis or liver cancer or there is need for liver transplantation. We don't want to wait, obviously, that long. You know, the key is to detect fatty liver disease early on and reverse it before it's too late in the game. And because it's silent disease early on, because it doesn't have symptoms, the key is screening.

And on that note, I would say if you do have metabolic risk factors, specifically type 2 diabetes, you need to be screened for fatty liver. You need to ask your doctor, do I have fatty liver? If you have high blood pressure, if you have high cholesterol, if you are overweight, if you have family history of fatty liver disease, if you have sleep apnea, polycystic ovarian syndrome, very common. You know, those are the signs in my mind to get screened for fatty liver disease. early on, you know, before it's too late in the game. Because when it's too late in the game, you know, it's difficult to reverse it, quite frankly, and it will lead to significant symptoms, such as jaundice, yellow eyes, sometimes distension in the abdomen, occasionally bleeding from the GI tract, affect mental status, et cetera. We don't want to wait that long. We want to find it

are you. Let's start off with an analogy of explaining fatty liver disease, but by explaining how important the liver is, you know, in the book, which is fantastic, by the way, we have the link in the show notes to pick up a copy. In the book, you talk about how the liver, if you are imagining a city that you are flying over, the liver is the public utilities, the public work utilities, and that's the role that it plays in the city. Kristen, can you take that analogy further and explain it to our audience just so they understand just what the role of the liver is? And then we'll talk about how fatty liver disrupts the liver's function. Yeah, so the liver is involved in essentially every metabolic process that the body has.

In our first book, Skinny Liver, we used a Rodney Dangerfield quote in the very beginning of it. And we said that the liver kind of is always screaming out, I'm not getting any respect. All the respects go into the heart and to the brain. And rightfully so. they're important organs as well. But the liver really takes care of every single process that we see from a macronutrient standpoint. So for example, when we look at sugar and we look at our consumption of carbohydrates and what happens to insulin, to glucose, to the stored form of glycogen, the liver plays a role in making sure that our blood sugar is constantly at a balanced level.

And it adjusts it as necessary. And oftentimes we don't think about the liver being part of that, right? We think about the pancreas and we just think about insulin. But the reactions that occur with blood sugar management are all tied back to the liver. When the liver feels that there is too much sugar, they can't use the sugar, then the liver is going to store some of that sugar as fat. So it also has a role in lipid metabolism, in cholesterol. So when we're eating fat, it has a role in how the breakdown of fatty acids are as well. And then from a protein perspective, the liver is involved in making sure that amino acids can be converted into energy. So as a dietitian, you know, the kind of 101 of what I learned over 20 years ago, the basics are that our macronutrients, our carbohydrates, our protein,

you know, our fats, all of that somehow has to get converted into energy. And that's what we use as fuel. The liver plays a role in that conversion factor in every single one of these things. This is why it's so linked to things like heart disease, like type 2 diabetes, et cetera. But really from a metabolic process, this is why we refer to it as kind of like the main thing that makes everything go, that makes everything communicate to one another. All of those organs are important, the heart, the brain, but the liver is what is making everything actually function. I actually, if I may add, there is another analogy which I use with my patient, I call the liver TSA gate. You go to the airport, you got to stop by the TSA, you

know, before he gets in. Same with the liver. Anything comes to your body has to stop, filtered by the liver before it gets in. You know, the bad guy's out, the good guy's in. And what happened when you have fatty liver disease, your liver is overwhelmed. There's so much fat, inflammation, et cetera. So some of the bad guys are going to get in. And that's going to affect your body. That's going to lead to fatigue, you know, sometimes pain in the right upper side of your belly. And then eventually, obviously need better damage you for cirrhosis. This episode is brought to by bioptimizers. Can you believe it's already the new year?

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in the liver that is causing it to malfunction and lead to a whole host of other issues down the line? Yeah, I can take that one. And, you know, just to make it simple, you know, fatty liver is, as the name implies, it's fat in the liver. If I show you a picture of fatty liver, you will see literally a whitish kind of, you know, liver with a lot of fat. And what happened, if you have fat in the liver for a long period of time, that fat will break down. And when the fat breaks down, causes inflammation. The inflammatory cells will come in and get excited, and that's going to cause inflammation and the liver. And when you have inflammation over long period of time, that will leave some damage, some scarring tissue. We call it the medical term fibrosis.

And when the scarring tissue, when fibrosis builds up, that will eventually lead to cirrhosis of the liver, which obviously can affect the function, the engine inside the liver, which leads to liver failure and need for liver transplantation. So when you start to understand that it's literally fat in the liver, these sort of like fatty deposits, one of the things that you both talk about in the book is that the term itself is a little misleading when it comes to unpacking what the hell is causing this situation in the first place. You think fatty liver, and immediately most individuals think, oh, okay, I guess it's the fat that's inside of our diet.

Kristen, from a dietitian's perspective, help us understand why that idea is misleading and what the real culprits are, not that there aren't many, there are many, and we're going to break those down, but what is the major culprit of fatty liver? Yeah, so I would say a mal, like looking at our metabolism, terms of how our blood sugar is managed. Let's start with that. So insulin resistance, anything where we are overloaded as we typically are in the American diet with sugar with refined carbohydrates, this is what is really leading to the up the storage of fat within the liver that then replaces healthy liver tissue. So yeah, fat is definitely, and fat has a role in it,

but not as great of a role as sugar does. So I look at this as when we look at sugar and we look at the comparison to fat. Really, it's similar to what we saw in heart disease, whereas years ago, we would think that saturated fat was the main culprit for heart disease. And if you just cut saturated fat, you're going to be fine. You're not going to get heart disease. Then we realized, based on research that came afterwards, and even an alteration of our dietary guidelines, that it was sugar, and it was an influx of too much sugar that then gets stored. So sugar is really the main culprit. This is why we took such a hard stance on looking at the carbohydrate content and some of our dietary patterns, which we can talk about later. But that's really what we're looking at. And I want to add

one other point, non-alcoholic fatty liver disease also has nothing to do with alcohol. And I think that's the other thing that we typically see. Someone will come in and say, well, I don't drink anything. I don't understand how we got this, right? But they might have some other risk factors. They might have an increased waist size. They might have insulin resistance, pre-diabetes, all of those things put them at risk. Yeah, I mean, I see it in my practice all the time. You know, there is a stigma with liver disease. When somebody has liver disease, it's like, like Kristen said, well, wait a second.

I've never had, you know, significant alcohol. How come? You know, when you say liver disease, people think alcohol. But really now the most common cause of liver disease is by far fatty liver associated with metabolic risk factor, diabetes, you know, overweight, high. blood pressure, high cholesterol, you know, those kind of things. And on the note of the name fatty liver, I agree. It's really good point. It's misleading. You know, people think if I eat fat, I'm going to get fatty liver. Makes sense. Well, it's wrong. If you eat carbs, you will get fatty liver. If you

eat too much sugar, you will get fatty liver. The problem is with sugar, not with fat. Yeah. And true, I would love to add that. So when we wrote the book, book, right? When you write this book, you have all the research in the world, and then sometimes research comes out after that. So one of the things that came out after that was really interesting was all of the liver-associated organizations actually changed the name from non-alcoholic fatty liver disease to metabolic associated dysfunction fatty liver disease. So it really saw the importance of the metabolic dysfunction end of it and taking away some of the confusion that a consumer might have or some of our patients might have, that this is just related to fat or

it's just related to alcohol. The metabolic dysfunction was now put in as one of the titles for how we look at this disease, which actually increases the accuracy of how we all look at this. Yeah, and it's a big part of what you both wrote in the opening is that since your first book that was there, skinny liver, what's that the name of me? Skitty liver. There's so much science that's exploded and you've incorporated in there. And that's also a big part of how you've come up with these four metabolic types that we're going to get into in a second. Now, before we get there, one of the things that I want to get a chance to touch on is that when you have fatty liver disease, non-alcoholic fatty liver disease, or this updated term, which is a mouthful,

but can you repeat it again, metabolic? What was it called? Dr. I'll let you, you'll say it Absolutely correctly. I'll have a word off. Yeah. You know, the metabolic associated fat-y liver disease. They're trying to find a new name. The new name actually fits a diagnosis of inclusion. It's associated with metabolic syndrome rather than a name of exclusion, non-alcoholic. It's something else.

So it's metabolic associated fatty-diver disease. It's fat-ed liver-associated with metabolic syndrome or metabolic risk factors. Okay. So for the purpose of this interview, I might still refer to it as non-alcoholic fatty lead disease. So I think a big takeaway when people follow your work, listen to your interviews, see the book, is that it's not that this problem is just isolated to the liver. This impacts every aspect of the health of our body and our longevity as well, which I know

is something that my audience is very interested in. So can you talk and I'll run through, we maybe run through a few categories that you've broken down in the book. Talk about how fatty liver disease, non-alcoholic fatty liver disease gets in the way of our long-term health and interrupts the function of other organ systems. Yeah. I believe to start, I guess, the conversation there, the most common cause of problems of death, if you will, in people with fatty liver is not liver disease, believe it or not. It's cardiovascular events, meaning heart attack and stroke. Meaning, unfortunately, we lose most patients with fatty liver disease,

not because of their liver disease, but because they get heart attack and stroke. And the reason why, because it turns out fatty liver is a risk factors to get heart disease and, you know, heart attack and stroke. So it's not just a liver disease. It's a multi-system disease. It affects other organs. Another important point here, fatty liver is associated with increased risk of cancer. Certainly liver cancer, but also other kind of cancer outside the liver.

Recent studies from Europe show that patients with fatty liver disease are associated with increased risk of chronic cancer, for example. So that's what to stress the point that it's not just a liver disease, it's really a multi-system problem. No, that's super helpful. And another area that this ties into, Kristen, I love for you to chime in on this is that you mentioned that a lot of your patients come in in the early stages and they might just think, I just have fatigue. Sure, there's a lot of reasons why people would struggle with fatigue. But in some instances and based on the estimates that are there, right around 30% of the population, at least here in North America, is dealing with fatty liver disease, non-alcoholic fatty liver disease. But there's another one, just like fatigue, this idea that they are dealing with, some level of chronic inflammation. So what's the connection between non-alcoholic fatty liver disease and chronic inflammation that could be impacting the whole body? Well, so number one, it is how the liver is impacting the rest of the organs, the ability for the body to be in a state of homeostasis. So being able to be in a place where the body is happy. The other thing we look at, though, is we really delved a lot into looking at things like waste.

circumference. And I know we'll get into that a little later. One of the things we refer to when we see someone who is carrying a lot of belly fat, a lot of fat in the midsection that is close to organs, we refer to it as kind of like this cytokine storm. So we know that when we have fat in the midsection, we're more likely to have insulin resistance. We're more likely to have that fat be what we would refer to as active. And that then increases inflammatory factors within the body. So, if we look at a very high level and look at inflammation as the base of any disease, whether that's a mental illness or a physical disease, we know that it's some place down the line. The liver is playing a role.

Now, we do have some instances where someone might develop fatty liver disease and does not have belly fats. It's more rare. A lot of times what we see there, which Dr. Hannanay could talk more about is more genetic abnormalities. But we do know that when the liver starts replacing fat with this healthy tissue, it no longer can take these processes that I detailed at the beginning of this. So being able to manage blood sugar, being able to manage our lipids, being able to convert the amino acids, and being able to make sure that we don't have too much ammonia in the system from protein sources, etc. Any place where that system goes wrong, we run the risk of having inflammation occur. So we're, of course, talking about systemic chronic inflammation that's unresolved.

That then can lead to chronic disease. There's a few others that were part of this list that you shared in the book that there also are connections to in addition to chronic inflammation. You have heart health, which you mentioned earlier, Ibrahim. You also have digestive health, bone health, reproductive health, especially for individuals that are dealing with PCOS, brain health. mental health, could you just touch on a couple of those and the connection and the link, just big picture between them, whichever one you choose, between those and the liver?

Yeah, for sure. Like we said earlier, I mean, you know, Fatty liver disease is not just a liver disease. I find I look at it as multi-system problem. And the heart comes first actually to mind, you know, because it's by far, like we said, it's the most common cause of terrible outcome in people with fat-ed-over disease. You know, another factor is polycystic ovarian syndrome. Patients with them, the vast majority indeed of patients with polycystic ovarian syndrome tend to have fat-ed liver. And that's why those patients need to be screened for fatty-divir find it early.

And actually, they tend to have more severe forms of fatty-diver. because of insulin resistance, they tend to have significant inflammation, which may progress to fibrosis and advanced liver disease early on. Diabetes is a big one. The American Diabetes Association now recommend that everybody with type 2 diabetes should be screened for fatty liver. So meaning, you know, even if you don't have any symptoms of liver disease and never ever been told that you have liver disease,

if you do have type 2 diabetes or if you know a family member or a friend with type 2 diabetes, you should make sure to get them screen for fatty liver disease. Number one, because if you have diabetes, you likely have fatty liver. And then there is a connection that fatty liver disease may also be associated with increased risk of type 2 diabetes and difficult to treat type 2 diabetes. If I could add in, sometimes we look at this, Dr. Hannanay and I, I have had many conversations about this, it's almost like a chicken and an egg approach, right? So it's like if you have type 2 diabetes, that that then lead to non-acoholic fatty liver

disease? And what was the fatty liver disease created by? Was it type 2 diabetes or is that creating a more severe form of it? So I think that's why we just keep going back to this concept that if we look overall at our metabolic health and what that means, we can really pinpoint what are some of the origins, perhaps to a diagnosis of non-alcoholic fatty liver disease. Well, before we get into metabolic health, I think it's an opportunity to just talk a little bit big picture and zoom out. You know, from my understanding, evolutionarily,

fatty liver disease is largely, again, non-alcoholic, is largely a more recent phenomenon in the evolution of human beings. Is that a fair understanding? And if it is, what the hell is going on in our environment, in our world that is leading to the perfect storm of events. You alluded to some of these earlier that are creating this silent epidemic and this disease that's impacting so many people. No, you're absolutely correct. Actually, Fatsy liver disease was first described in Minnesota, where I practice and live and not too far from here in Rochester at the Mayo Clinic in 1980.

That was the first time, you know, somebody described. fatty liver disease associated with metabolic syndrome, diabetes, and obesity, and such things. So it's not like, you know, I mean, it's not a very long disease. And why we are seeing more and more fatty liver, why one out of three individuals out there have fatty liver? Well, number one, I think, you know, we are consuming more sugar, that's for sure. We're consuming more carbs, which leading to diabetes and weight gain and incident is a thing. And as a result, fatty liver. And also if you look, there's a nice study came from the WHO the other day, which

look at the number of calories, the amount of calories like, you know, we've been consuming between 1970 and today, and you see the graph is just going up. So I think, you know, it's related to the amount of calories we've been consuming and also the quality of the calories. It's a lot of it coming from sugar and cars. That's why, you know, we are seeing more and more fat. We can also see a parallel with an increased diagnosis of type 2 diabetes. And really, as a dietitian, I know I'm biased here, but I look at the changes over the past 50 to 70 years in our food industry. Right. So how is our food

changed and how does that contribute to some of these metabolic disorders that we're now seeing more? So yes, of course, we have better diagnostic techniques and a better way to diagnose. knows people. So that's, of course, always one reason why we might see an increase. But really, we have a huge influx of ultra-processed, hyper-palatable foods. We have an environment in which people are consuming foods that they are not able to stop eating, that the food is changing the way their brain works and they literally can't put it down. I make this joke to my patients that when you have a really stressful day or you have a fight with someone and you just, you feel in the stress. No one is saying, I can't wait to get home and have a kale salad, right? You pick your

poison on that one. I can't wait to get home. I'm going to have a pizza. I'm going to have a bottle of wine. So we have such an area right now in our health where a lot of my patients have turned to food to help manage whatever they're going through. And so we have a change of food throughout the last 50 years, but we also have people abusing food in much greater numbers than we were when our grandparents were around and additives that we didn't see back then. So I think there's, we could talk for hours about how the food industry really has kind of changed the game and increased some of these conditions and diseases. But as a dietitian, that's the main thing that I'm looking at. How is our food evolved? And how do we get a more nutrient dense option

on our back on our plate, which is much easier said than done? It's such an important reminder. and it really brings up this larger topic, which is, I give this analogy, that if you go to Times Square or some major sort of thoroughfare and you do a little bit of man on the street, woman on the street sort of interviewing style, and you go up to the average person, you say, hey, do you eat a healthy diet? The vast majority of people are going to say, yeah, I try to be healthy or, yeah, I'm pretty healthy, no matter what they do. Generally, this has been my experience.

And largely, the reason that you get that answer is that processed sugar and simple carbohydrates are so baked into every aspect of our life and ultra-processed foods are so normalized in everything that we do that it feels normal. So for most people, they think that this is normal. Even if they're struggling with health issues, well, guess what? Everybody knows somebody that's struggling with more health issues than they are. So that person thinks that they're the healthy individual. And inside of the book, one of my other favorite sections was you have this entire section.

Maybe Kristen, you can expand on this a little bit, this entire section to help people understand that we're not talking about, you know, a dessert here or there. We're not talking about a piece of dark chocolate that's sweetened. You know, we're not talking about adding a little bit of honey to your tea or even putting some sugar inside. of the coffee that you make at home. We're talking about these pharmacological dosages of sugar that we're surrounded with on a daily basis that are not just in desserts, but are in things like pastries, they're in things like breads, they're in things like pasta sauce, and they have a lot, a lot, a lot of different names on the package that are not just sugar. What are some of those names that are out there where people who are even listening today saying, well, I don't really

think that I eat a lot of sugar, but I think that I might be struggling or I know I'm dealing with non-alcoholic fatty liver disease. So what are some of those names that are out there? Yeah, it's interesting. You know, I had a patient that Drew come to me and say, well, I don't, I don't consume any high fructose corn syrup. I don't know why this happened, right? And it was just really interesting because once we started looking at her diet, she had a lot of honey in her diet. And again, small amounts is okay. But looking at just kind of some of these, what I noticed with my patients, some of these keywords that people think imply a healthier version of sugar. So like pure cane sugar or looking at like brown sugar, people think that there's a little bit more

mineral in that. And so there's benefit to that. Looking at molasses as a better option. Those are ones that we see more likely than not. I always go back. to I'm half Dominican. And so, and the summers a lot of time, I remember that we would get sugarcane from the fields. And we would just suck on that. And that was dessert. That's a very big difference from what we see today, which is a child going into a movie theater, getting a king-sized bag of licorice and downing the whole thing coming out of that

movie theater and saying, I'm starving. Where's dinner? Right. So I think like from that perspective, I think a lot of people just associate that. If they're not having high fructose corn syrup or if sugar's not coming in the first few ingredients, then that's okay. But really, we have to look at all these other options. Honey is a great example where honey is great.

It has a lot of antimicrobial effects. We've got some great studies on it. But if you have too much honey, honey's not tied to fiber. So anytime you have a sugar not tied to fiber, your blood sugar, your insulin, they're going to go on what we call the roller coaster. and that can lead to more inflammatory responses, that can lead to fat buildup in the liver, et cetera. So I think that's really what I'm trying to pinpoint with my patients is that anything that's going to increase your blood sugar

is going to impact your risk of napold. Really? And so whether it's honey or whether it's having some dried cranberries or whatever that may be, the source matters. I think that high fructuous corn syrup got a really bad wrap in the early days of NAFOLD. But I think now we see anything that's going to increase your blood sugar is going to be the

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and you can sign up for their app. New users of their app can use the code Drew, D-H-R-U-5. That's Drew 5 for $5 off any order that you place within the app. So check out Sweet Greens and their new protein plates today by going to Sweetgreen.com and use the code Drew 5 for $5 off. Now, that to be said, just to jump in, as a lover of honey, the vast majority of people that have, you know, fatty liver disease,

non-alcoholic, they're not ending up in that situation because of a regular consumption of honey. It's primarily ultra-processed foods that are there for them, that they're consuming. Even for most people, if they try to consume the amount of honey that you would need to trigger, you know, fatty liver disease. It's a lot of honey. And most people, I probably have at least a tablespoon of honey a day that I might. I do too. Yeah, yeah, yeah. So just everybody's clear, like, there's a lot of benefits to honey. And it's not that that's why people are ending up in that situation. Yeah. But you're highlighting the fact that when sugar comes into our lives through all

these different forms and for the vast majority of people, it's going to be liquid calories is a huge part of their exposure to sugar, at least on a daily basis, whether they be soda, Starbucks. In fact, I saw the dietary menu and the nutritional facts for a new concept restaurant that McDonald's is launching. It's a competitor to Starbucks. Oh, I've seen it. Cosmix. Cosmics.

And there are multiple drinks that are on that menu that are there in this proof of concept restaurant that are 100 grams of sugar in one drink. And there are other multiple ones that are in the 60 to 80 grams of sugar all from one drink, no fiber, and immediately sort of downloaded into your body. That's probably the type of things that are most connected to the pharmacological dosages of sugar that people are getting in their regular lives. Absolutely. It's not, you're right. You're absolutely right. It's not the, you're not going to have excessive honey lead to this. I think my point is, you know, I think about like my interactions with my patients. I had a patient come to me once and she said, this was like first thing out of her mouth. Lovely woman. She said, I haven't had sugar in 10 years, Kristen. Can you believe that? And I was like 10 years.

Wow. Like that's like, that's amazing. Tell me how you're doing it. And she's like, well, I only consume agave. And I'll use it. And I'm like, okay, well, that's a, but that's. another form of sugar. So it's just an extreme example and you're right. If we look at individuals that only use honey and not other sugars, we actually have studies showing that they're more likely to have other healthier habits and actually have a very lower sugar diet. So you're absolutely right from that perspective. You know, the data from 2014, so this is many years ago, from the CDC showed that I think it was around 68% of our youth are having a sugary drink at least, every day, if not more. Right? It's 68% and adults were something like 43%.

Okay, every day having a sugary drink. So even just looking at the pinpoint of what are we drinking? Yeah, I think you mentioned this term liquid calories. So what are we drinking that fills up our body with space, but not with nutrients? So we now have this inability to fill it up with nutrients because we're just not seeking them. We're seeking some of these other things that that may also have some addictive properties as well. Yeah, the other problem also with the sugar and sugary, you know, juice and, you know, you'll end up craving food more often. So technically what happened, if you eat sugar, you know, your body is going to produce incident, right, because you need to lower that sugar down. And when you have too much incident on board, then that incident

stimulate your liver to make fat. So you end up having fatty liver. And if you have fatty that will lead to incident resistance. And incident resistant, guess what? It will cause craving. And so you'll crave more sugar and you will eat more sugar and you go into that kind of vicious cycle where you kind of you get locked. You know, you feel like, you know, you need to consume more and more sugar. Yeah, it's so true. You know, there's a an analogy that is sometime given. Well, I guess it's not really an analogy. It's an explanation that if you look at some, and you guys, tell me if there's any truth to this. I've heard a few people say this. And I'm not a consumer of this product, so I don't know the exact details. But they say if you look at something like

Fagua, which is a delicacy, essentially the way that Fagra is made is that you're feeding ducks, a lot of carbohydrates. You're force feeding them in some states. This process is actually outlawed. I think it originally came from France. You're force feeding. these ducks, carbohydrates to fatten them up. And in turn, their liver fattens up. And then when the animal is ultimately slaughtered, that fatty liver that has all this marbalization and this stuff, which is not good for humans and not good for animals,

ends up being a delicacy that some people eat. But if you ever wanted to understand what causes fatty liver, that's a perfect example in ducks in fact i even think the french term for fatty liver is foie gras am i understanding that correctly does anybody want to want chime in on that oh boy i don't know what the french term is for i'm almost positive i'm almost positive that i've read this multiple times i'll have my team fact check it at the end of it in fact i did just a quick google search and it says faul gras is french for fatty liver so that seems to be exactly what it is So if we can induce it in animals, which is, again, horrific process, right?

We can induce it. And in a way, we have a nation of individuals because our food is hyper palatable. And we have this overconsumption of calories. In fact, you guys have a term for it. We have this explosion in foods that are, you call them, unput-adownable foods. Which I love. So you have human beings that are largely putting themselves into, pardon the analogy, almost like a factory farming situation where they're inducing fatty liver on themselves

through the hyperconsumption of ultra-process calories with a huge portion of them being simple carbohydrates. You know, we're not talking about fruit. Right. We're not talking about the inclusion of, of course, vegetables or carbs, which are not simple carbs. We're talking about highly refined processed sugar in all its different forms. And we need to put a stop to it because based on the metrics, I'm sure you guys know better than anybody else, you know, this just continues to go up every single year. And, and, and, and doctor,

even for you, like, how young are you seeing patients come in or in the literature that are struggling with fatty liver disease? Oh boy. Yeah. It's a huge problem. in young individuals, which is really sad. We are seeing the disease affecting young individuals for all the reasons we mentioned. And unfortunately, because if the disease affects you early on in life, you're probably going to end up in trouble when you are in mid-40-50, meaning early on in life, get in trouble, you know, because of heart attack, stroke, liver disease, etc. So this is a huge problem in young individuals. Indeed, studies published recently in the New England Journal of Medicine showed that, you know, fatty liver disease affect approximately one to two out of five individuals with young individuals out there, you know, have fatty liver disease. The other challenge with that, and Dr. Hedanae brought this up briefly is that, you know, when you get it, you know,

young, you have, you give that, deliver the opportunity to let it just go completely in a disaster mode. Sometimes if you develop this condition later in life, it takes the liver a long time, sometimes to get to these latter stages, which we can discuss. But when you get it young, you, you've got time. You got time on your side. And that can be a challenge too, because it, a lot of times in these cases, it's about weight loss for the child. But it can be challenging to have that discussion or to try and address weight loss in a child for many reasons. It's a different approach than we have when we have an adult sitting across from us. So there's a lot of challenges associated with it. Really at the end of the day, the research is very clear that dealing with

the parents tends to be the best approach to helping a child alter their diet. Well, in the midst of all this saddening news and heartbreaking news that's out there, there is a silver lining. And I'm going to quote from the book. You say that the two of you say the good news is that except for the final stages, thanks to the liver's regenerative properties, which we're going to chat about more in a minute, fatty liver disease is absolutely treatable and even reversible. Dr. Ibrahim, can you talk about that for a second?

You know, a lot of people don't know that that's actually the case. So talk a little bit of that hopeful silver lining that's there to give the audience a least a little bit of a breather that there's something that they can be doing about this. Yeah, absolutely. So, yeah, fat liver disease is a treatable disease, particularly if you detect this early on in the course of liver disease. Like you said, Drew, the liver has a capacity to regenerate. And I'll give you a little bit of analogy or story right there. We do live donor liver transplant, you know, all the time. Live donor liver transplant, where You take a piece of a liver, just a piece of a liver from a loved one, and you give it to a patient who need liver transplantation.

And if you scan the donor and the recipient just a few weeks, believe it or not, just a few weeks after the surgery, the liver is back to the original size. You put a piece of a liver, and you do scan a few weeks after the surgery, the liver back to the original size. It's almost like a science fiction. and that speaks volume for the capacity of the liver to regenerate. Indeed, there is no other internal organ in the body that regenerate. And the mechanism of regeneration is poorly understood. I think one day when a smart person identifies the mechanism of regeneration will really change the medicine, the way we practice medicine.

But I provided that example just to give the audience an idea about that the liver and regenerate. So if you find fatty liver, particularly early in the game, and you fix it with changing your diet or some other things which we will talk about, you could go back to normal, completely normal. And even actually at later stage, more and more studies now suggest that even if you do have cirrhosis of the river, you may still have window opportunity to reverse the damage. So yes, fatty liver disease is preventable for sure and certainly, certainly reversible and treatable.

And I think, Drew, if I could add this, I think one of the key factors here, and one of the reasons why we really wanted to focus on liver health with our second book as well, is that we still lack any pharmacological approach to being able to treat this disease. So this is really a lifestyle type of approach. You know, in any other major disease, we look at heart disease or even looking at medications that can slow decline in Alzheimer's and dementia. We have a pill for most things. We don't have a pill for this. So I think our point here is not to be doom and gloom and say, oh, gosh, you know, all these people have fatty liver disease.

And if you don't fix it, you're going to die. There's such a huge opportunity. There's actually more beneficial news than we have. than negative news and how to reverse this. But it is lifestyle. It does take lifestyle change. And so that's the big difference between this disease and other conditions that are that are simply solved sometimes with taking a drug.

Yeah, like a wise man once said, let the food be your medicine. I think this is the perfect example where technically the food is your medicine. There is no medicine approved by the FDA out there to treat fatty liver disease like Kristen said. So a little recap is that not only is fatty liver disease absolutely treatable, and reversible, except for in the final, final stages, which we talked about a little bit earlier. But food is the pathway to do that because there's not pharmacology. There's not drugs right now that can intervene.

And food is the perfect tee up to going back to this important topic that you started off with, Kristen, which is metabolic health. We've done so many episodes on this podcast here about the importance of metabolic health. what happens when metabolic health gets out of whack. But let's just give a little bit of a refresher from either one of you about just metabolic syndrome and metabolic health and how those things, when they're going on in the body, in addition to what they are, they set up a situation for the liver to essentially be overloaded. Yeah, so I can tell you about the kind of the inclusion criteria for metabolic syndrome.

and then maybe Dr. Hannanay can talk about a little bit more of the more medicine side of it. You know, when we think about metabolic syndrome, it's really looking at a combination of factors. So we'll look at things such as blood sugar, such as your lipids, such as waste. So in men, we want our waste to be 40 and below. Women, we want it to be 35 and below. So we'll look at all these factors. And if you are kind of checking the box to at least three of these factors, and you are someone who we would say, you have metabolic syndrome. So that's kind of a general term with having some sort of dysfunction in this area.

So whether that is your, you've got hyperlipidemia or you're pre-diabetic, your hemoglobin A1C is not quite at type 2 diabetes or even insulin resistance, but you're kind of knocking on the door, right? All of those things are things that we would say, you've got this metabolic syndrome, which means you've got a cascade of things going on that might lead to dysfunction. And again, because the liver is involved in all of the metabolic processes, which will touch metabolic syndrome, this is why the liver oftentimes is involved in any kind of diagnosis of that. Dr. Hannah, and I'll let you go into any more science from the medical form of it if you'd like to. Yeah, no. Metabolic syndrome, like Kristen said, you know, you got five factors, including the metabolic syndrome. You know, central obesity, diabetes, particularly type 2 diabetes. high blood pressure, high triglyceride, and low HDL.

You know, HDL, the good cholesterol. If you have low HDL, that's a bad news. So those five factors, if you check three out of five, you have metabolic syndrome. And what happened if you have metabolic syndrome? You're going to have insulin resistance. What's incident or resistant, meaning the incident in your body is trying to get its job done, but unable to. Your body is resisting the incident to get the job done. and what happened as a result of that,

you're going to produce more incident. And if you have too much incident on board, like we said earlier, that's going to stimulate the liver to make fat and to store fat, which technically leads to fatty liver. So that's kind of the mechanism, if you will, of why if you have those factors,

diabetes, high blood pressure, high cholesterol, central obesity, you've got to be screened for fatty liver. You've got to think about fatty liver because you have the makeup, if you will, the path of physiology and makeup to set the stage for fatty liver. That's fantastic. It's a perfect opportunity to get into one of the central themes inside of the book,

which is helping people identify what their metabolic type is. And there's these four different metabolic types, and I'd love to get a chance to walk through them because this will help the audience understand that, as you guys have mentioned, traditionally, it was thought that obesity was the primary thing that was associated with fatty liver disease, non-alcoholic fatty liver disease. But the deeper you get into it, and now that the word metabolic is being brought into the new and updated term for explaining what fatty liver disease is, there's an understanding that you could be skinny, you could be lean, there could be a lot of

different things that are going on. So let's start. off with the first one. Who wants to break it down? It's the preventer. Preventor? Is it the one? The preventer. Yeah. The preventer is someone that is healthy and lean. So what does that mean? Let me back up and just talk about how we kind of devised how we were going to break these down. One of the things that we found really critical to our assessment of how we put someone in a dietary plan or even just discuss what their mode of treatment should be is really taking away this concept that BMI means something significant. We have studies now that show that BMI is not a great factor. A lot of times we'll go back to this example of Arnold Schwarzenegger, right? He's just like all muscle, his BMI is going

to be sky high. And so that's not a great assessment. Now, of course, he is kind of like an outlier. But what we know is that BMI is a really poor indicator of health. And I can tell you from my patients, my patients oftentimes would come to me and say, well, my doctor said I'm a class one obesity and I just felt like I felt like I was been shaved. Right. So like there's a lot of things that are not great about BMI, even though we use it as one of the structures of assessing overall health. The preventer is healthy and league. So that what that means in terms of our metabolic types is that the healthiness is going to be associated with two things. What are those numbers that we've been talking about this whole time? What about your lipid panel, your hemoglobin A1C, all of that?

And how does that combine with your waist circumference? Waste or circumference? Waste or is a much better indicator of health than that BMI. I often say that the scale or BMI, it tells you all your stuff. That's it. It's just stuff. You know, when you come to see Dr. Hannanay or myself at the Cleveland Clinic, when you came to see us, we would put you on a machine and we would assess every limb, your trunk, and everything would break down your fats and your muscle and your water.

BMI and weight don't do that in terms of standing on a regular scale. So a healthy and lean individual would be just that. They don't have any of those criteria. They don't have high lipid panel. They don't have high hemoglobin A1C. And their waist circumference is at a normal level, right? So if they have non-alcoholic fatty liver disease, most likely there's something genetically occurring that we might be seeing or something else that's manifesting it that might not be diet related.

That was a really long answer to that, Drew. But I wanted to get into that basic. is why we love long format podcasts because the audience that's here, you know, this is not being covered on the mainstream news. You know, there's not a lot of places that people can go to to get the details on it. Should we tee up the next ones that are there, the rest of these three for whoever wants to jump in next? I'll just summarize them. So we have the preventer, the fine tuner, the recalibrator, and the regenerator. So let's go into the next one. Who wants to take on the fine tuner, which is somebody who's healthy and non-lean. If the preventer was healthy and lean,

the fine tuner is somebody who's healthy and non-lein. Okay, so healthy and non-lean would mean that their numbers are still looking pretty good. So maybe your lipid panel looks okay, your cholesterol. Your HDL is kind of high. I mean, your HDL is high, which we wanted to be. But let's say your other things like LDL and cholesterol are within normal range. You're just kind of hovering a little bit high, not enough for a pharmacological approach. Your hemoglobin A1C is okay. All that's great, but your waist circumference is too high. So again, if you're a male, it's going to be over 40.

And if you're female, it's going to be over 35. So you're showing some belly fat here, but you're not showing the other signs that a doctor might look at and say, oh, gosh, you also have a high blood glucose that's fasting. You probably have non-alcoholic fatty liver disease, right? So you're lacking that one other part. So that's why we call it the fine tuner. You're probably going to need to lose some belly fat, and that can help you prevent being diagnosed with fatty liver disease, maybe later in life. But for the most part, you're doing pretty good.

You just have some excess weight that you're carrying in the middle. Fantastic. So the next one here is the recalibrator. So recalibrator. So recalibrator is really looking at the concept of being unhealthy. and being lean. So this is kind of the opposite of what we just talked about. So unhealthy means your hemoglobin A1C might be elevated. Any of those numbers might be elevated, but your waist circumference is within a normal range. Right. So here we have a case where, okay, now we're really seeing

the metabolic side of it. We're not seeing the central obesity, but for whatever reason, some of these other things are occurring that might put you at risk for the disease as well. Ibrahim, if you want to take the last one, which is the regenerator, unhealthy and unlean, that is kind of like, we want to cater to all people that are going to be reading our book. But this is really the patients that have the most risk. Yes, indeed. Yeah. I mean, if you think about it, if you have that belly fat and you have metabolic risk factors, diabetes, high blood pressure, high triglycerite, low HDL, and then this is the category that we call man lean because of the body fat and unhealthy because metabolically you're unhealthy and this is actually the biggest group at risk to develop complications fat liver disease

this is pretty much what I see in my clinic quite frankly and this is the group that I get a little nervous about I get more you know serious about we got to be on board to get those metabolic risk factor under control to lose that body fat, you know, because this is the group that likely, unfortunately, developed complications such as heart attack, stroke, or liver disease, and in certain scenarios, liver cancer. So this is the vast majority of people that are out there in sort of the population that are struggling and might already be diagnosed with fatty liver disease, non-alcoholic fatty liver disease, but don't know it. They have it. So I guess it wouldn't be a diagnosis. so they have it, but they may not actually have been told that they have it.

I have a personal question. You know, a lot of people from my background in community, the Indian community, they fall into this category of skinny fat. You know, they're lean and they're thin on the outside, right? Often skinnier arms, skin your legs, under muscled, but then a little bit of fat on the inside. A lot of visceral fat, belly fat, abdomen fat that's there. Would those individuals, and many of them, I forgot to add, even some family members and friends, were very surprised to see themselves diagnosed with non-alcoholic fatty liver disease.

Yes. And so those individuals, would they find themselves in the category of the recalibrator? Is that accurate? Yeah. Yeah. Those are your classic recalibator. So the skinny fat approach is really looking at an individual that they're not considered by means to be overweight. They're within a normal weight, but their numbers are not normal. So that is a huge risk factor as well. So even though they might be lacking that central obesity, or maybe

they're not at the level, right? Maybe if you're a male, your waist is, let's say, 43, but it's not 55 or 60, right? You still have what I would consider to be some of the greatest risk factors because your numbers, especially things like blood sugar management, your hemoglobin A1C, your insulin, you're triglycerides from the lipid panel, those things could be off. And so once those are off, and this is part of why it's also like this silent approach. We often talk about blood pressure being the silent killer because we can't feel when blood pressure is high. For the most part, if we have a generally elevated blood sugar and we're not a diabetic, so we're not going to have an event, we might not know that that's occurring.

So it's another great example of how this can really kind of creep up on you. Those are classic recalibrators. Just because you are not considered to be overweight or obese, doesn't mean that you're free from risk. Yeah, and Drew, your point well taken. Actually, that's part of the reason why Kristen and I, we decided to look at fat liver from those four metabolic kind of categories. I must admit I see a lot of patients in my clinic from Asia, India, you know, like you said. You know, it's hard even to tell them to lose weight, you know, because they're really, they're skinny. Yet they have fat liver.

And that's where you want to focus on management of metabolic risk factors, you know, get their sugar under control, blood pressure under better control, cholesterol, et cetera, and take a closer look at their diet. In my experience, in the Asian community, I think too much consumption of rice is associated with increased risk of fatty-diver white rice in particular. That's so important, you know, especially in this global economy that we all live in, in this global world, a globalization, China and India have, you know, the largest populations that are out there. And in India in particular, you see this explosion of people who generally, the obesity

rates in India are not as high as North America. or sort of, you know, some of the countries inside of Europe, but in particular North America, but you still see every year the fatty liver, non-alcoholic fatty liver disease going up, and largely, even though there may not be the prevalence of ultra-processed foods that is on every street corner, the way it is here in Los Angeles or New York or, you know, in middle of America, those may not be there yet. It's getting there, right? You're starting to see a lot more subways and KFCs and McDonald's and other things that are out there.

soft drink, sugary things, you're starting to see a sedentary lifestyle. We're exporting that lifestyle out, but still, their rates of non-alcoholic, value of disease are growing because one thing that's made it there still is just the explosion in these simple carbohydrates and the sugars that are inside of their diet. So they're at just of high of risk, even if their obesity rates may not be as high as here in America. And even the cultural perspective of amount, right? So I know you're well aware of the blue zones and all the different types of blue zones. But you look at like women in Okinawa and there was a study that was done. It's really fascinating. Just looking at their consumption of white rice and their risk of breast cancer. So they took these women and this is an old study. But basically after about 10 years in the United States, the risk of breast cancer was the same as an American woman. Right. So there was something about taking them out of the environments and the normal portions that they were used to and then coming over to the Western culture where portions are like huge and everything about it is huge. And, you know, we look sometimes, sometimes it's just about the food. Whereas in other cultures, a lot of times it's about the community. It's about sitting across from someone and having a conversation. We don't always have that as well as some other cultures. So there's there's so much that can really be unpackaged from that.

food perspective that we see here in, of course, the standard American diet or the sad diet that you don't see in other places, even though it's creeping in there. That's such an important point. And it really goes to this larger conversation that I have started to lean into on the podcast, especially last year a lot more so. You know, the thing is, is that, yes, these pharmacological dosages of sugar that you guys talk about in the book, they are the main drivers of this. They are the main culprits.

and sometimes because there's individuals that are out there that are not as nuanced as the two of you are, where yes, sugar is the problem, but we don't want to make sugar in any form the enemy. You have individuals that are watching interviews on YouTube or see things on social media that think, I need to cut out every aspect of sugar, even fruit from my life completely. And, you know, a lot of the data that's out there in terms of what causes people to fail when it comes to any dietary intervention is the more rules that you add in, the harder it is for somebody to maintain that lifestyle in the long term. And that's the primary reason why people get off of any dietary intervention as a whole. And the important piece to that here is that you have

other societies that will still be having some moderate levels of sugar, alcohol, other things. but the fabric of their society is not an overindulgence. It's community, it's support. It's a healthy amount of walking that's there. So yeah, some dark chocolate or even dessert. There's many societies that are out there that might have a little bit of dessert. You know, it's probably going to be homemade, right? It's not going to be, you know, this package thing that they're picking up from a big box store or at least locally made.

And they'll have dessert regularly. but because they're watching their overall caloric intake, not that it's all about calories, but they're not overeating on especially ultra-processed foods, they're able to partake in some of the joys that are out there in life, whether that might be alcohol for those that choose, or it might be some form of sugar sprinkled into your lifestyle and diet as close to sort of whole foods as possible.

And they're still largely okay. What we're seeing, though, is that that's starting to shift, even in a lot of these societies out of there previously, because as soon as you have ultra-processed foods in the mix, and you have these bigger box stores and these fast stores, we literally cannot control ourselves. These foods are hijacking our brains, and it causes people to be in a place or contributes to people to be in a place where they just cannot stop eating. Anything you want to add to that or anything that you disagree with that, either one of you? You know, it's interesting. When you were saying this, Drew, I thought about, I, this was

like a year ago, but I had an Instagram post up. And it was a picture of me and my two boys. And it was at a local donut shop. And it was a Sunday morning. We were all sitting there eating donuts. And I had someone like send me a direct message like, well, I really loved following you until I saw that he had a donut. And I thought to myself like, well, that's so interesting, right? So what I have is a lot of patients that will say, I can never have a donut, never have a donut. I can never have a donut. And then they have a dozen donuts. So there's a difference exactly to what you said, to having that a dozen donuts versus I'm going to have a donut on Sundays with my boys. That's going to be our tradition. It's part of what we do as a family and what I do as their mom. And I'm not going to feel shame or guilt.

And the rest of my diet's going to look pretty good. We do talk about that a little bit more high level in the book, really looking at this kind of 80, 20 approach. But I couldn't agree with you more. there's a lot of studies that have come out in the past few years, looking at why New Year's resolutions fail, right? Why do we stop doing them in February, things like that? So there was a 2021 study that came out, and two things that really stood out, number one, a complete lack of flexibility.

So saying you can never have something, feeling that deprivation, having that concept with food, that food is good or bad, and there's nothing in between. There's no gray, right? It's either good or bad. which is not a good way to look at food. So that was kind of number one. And then there are just goals being too general.

Like the goal of like a patient coming into my patient to my office and saying, I want to lose 50 pounds. This is my goal. You can't even comprehend what that looks like where you're sitting right now. But let's work on I want to lose three pounds in the next 10 days. That's a more realistic goal. So that's really one of the things that I completely agree with you at. and that what we really try to achieve is that even though we have these different metabolic types,

and we're going to put them in as a suggested dietary approach, we are very clear that people could go in and out. And really, in any scenario, you can pick and choose what works for you in any dietary pattern. It doesn't have to be that you are one dietary pattern and you are never, you know, deriving from that. Really having that flexibility is what we want people to achieve, because that's, that actually helps them improve their eating habits to begin with. There was actually one study came to mind now that looked at all of these diet program, you know, low-carb diet, the keto diet, the Mediterranean diet, blah, blah, blah, et cetera. And it turns out, you know, the best diet that works for fatty liver disease or metabolic syndrome,

guess what? The diet that you likes the most, you know, the healthy diet that you likes the most. because you've got to be friend with your diet. If you don't like what you're doing, you're going to be probably successful short-term, but you're not going to be able to maintain long-term. And quite honestly, that's the primary reason why Kristen and I kind of, you know, we didn't go into the keto diet.

We don't go deep to recommend the keto diet to treat fatty liver. The keto diet is certainly a diet that will help you lose weight short-term, but it's very difficult to maintain that kind of diet long. long term. So I guess, you know, the point is the best diet is the one that you'll be able to stick to it, that you're going to like it, you know, healthy diet that you'll be able to stick to it on like it long time. That's well said. And on the topic of, and on the topic of diet and foods, I keep teasing it and we're going to get there. You know, you have this section in the book. It's called feed your liver. These are 12 liver-friendly foods that you've highlighted.

in there, a bunch of them, a lot of them that are my favorites that are important because we don't want to go from one extreme to the other. And one extreme is, hey, just eat whatever you want, as long as you manage calories, even if it's ultra processed, you know, it's all good. Just manage calories. Let's say that that's one extreme. And sure, that might work in the short term and help with weight management, but especially when it comes to somebody that's already well on their way of suffering with non-alcoholic fatty liver disease, it's probably not the thing that's going to help you end up healing, you know? And then the other extreme is you have to cut out sugar in every single form, right? And here you guys are in the middle and you're saying, look, there's a bunch of different ways to roam.

And the key, though, is it has to be built on a foundation of whole foods. But the beautiful part is there's plenty of whole foods that support your metabolic health that are actually enjoyable. But before we get into that, we have a couple more things that we want to be able to touch on. So stay tuned for that. One of the first ones that I want to do that I just want to put a bow tie around. So if the person's listening, if somebody's listening today and saying, wow, I think I find myself in one of these metabolic types, especially the latter, the regenerator. So much of the value of these podcasts is people learning. what should I go ask my doctor to go test when it comes to my health, to know, am I struggling or

am I on my way to struggle? So if we could get a list of tests, because some of these are regular part of screening, and some of them that you mentioned, like fasting insulin, you sometimes have to ask your doctor for some of these tests or kind of nudge them a little bit. And you'd be surprised how many people listen to this podcast and hear, an expert like you guys say, you know, let's make sure your hemoglobin A1C isn't there. Let's make sure your fasting insulin isn't. And they're like, my recent blood work didn't include some of these options that are there.

So who would like to give a little rundown of the key tests that are there that are important for everybody to scream, but in particular those who are concerned that they might have or on their way to having fatty liver disease? The good news is actually nothing too special, quite honestly. The routine blood test that, you know, you probably had it done already during routine annual physical, should take care of things, should be able to tell us if you have fatty liver disease or not. But to be more specific, you need complete a blood count, which is a blood test, you need liver function test.

And I always like to check the kidney function as well. Hemoglobin A1C will be able to tell us if you do have diabetes or pre-diabetes. and that should be enough in terms of blood test to give us an idea whether you have fatty liver disease or not. Some people add insulin, if you will, in order to measure insulin resistance. I don't necessarily find it very necessary all the times. I guess one size doesn't fit all,

but it may give us more information about insulin resistance. But that's pretty much in terms of blood tests. And most of these blood tests done a tuning routine annual physical. So to say it again, CBC, complete the blood count, LFTs or liver function test, and hemoglobin A1C. You know, if you do have history of high cholesterol, et cetera, or if you haven't been screened for high cholesterol, I think lipid panel would be also necessary. And in terms of picture of the liver, I think picture of the liver was something like ultrasound or a test similar to the ultrasound called fibroscan, which is almost like an ultrasound machine. They put probe against the liver in the right side of the abdomen. And within literally a minute or two should be able to tell us if you do have fat in the liver, how much fat you have, does this fat cause any inflammation or scarring of the liver?

and how much scarring you have in the liver. It's a very easy, quick, cheap test that can be. So, routine blood test and a scan of the liver, that would be at least the first step for me to go. Fantastic. You know, inside of the book, there's a whole section that's there talking about who is at risk for this. And you break it down into a few categories.

Some of the key things that are beyond your, your control that might increase your risk of fatty liver disease, non-alcoholic fatty liver disease, and then some of the things that are definitely within your control. Let's just quickly go through some of the things that can contribute that are not within your control, but people should be aware of because if you are high in a lot of these things or as you age, which is one of the first ones, you might be at greater risk that's there. So who would like to tackle these? We have age, the implication of how you're.

hormones age over a period of time. We have the length of time your metabolic health has suffered. How long? Are you a child where time has not been on your side and you've had exposure forever? What your mother ate in utero, which is very fascinating, and of course your genetics. So let's start off with age. So, yeah, I mean, as we age, we are more prone to fatty liver disease because we're more prone to other conditions as well. Where I see this the most in my practice from this non-modifiable risk factor is even some of my healthy patients that are going through menopause. So they go through menopause. They're much more likely than to have issues with blood sugar management, lipid management, and that then gets them

more at risk for fatty liver, even though this was never a risk factor prior to menopause. So this is looking at the hormonal changes as well. And you kind of already mentioned it, but looking at children. So children are less likely to have this go to the latter stages of the disease. But as they age, of course, the longer they have it, so that hits two tickers on that one, the longer they have the condition, the more damage that is done and the more time that is provided to do that damage. So those are just some that I see within my own practice. That's fantastic. One other big factors, which is obviously out of our control genetics, you know, that's why. why if you do have family history, if you know somebody in your family, genetically related

with fatty liver, you got to ask your doctor to get you a screen for fatty liver disease. Unfortunately, some of us have a genetic makeup that set the stage for fatty liver, even with normal weight. And you got to know early on before it's too late in the game. Fantastic. And there's also this one that we didn't touch on, which is what your mother ate in your utero. super fascinating. So when you, any of us, were inside of our mother's womb, how does what she ate impact our risk of fatty liver disease? Yes, some of the studies that we looked at

for that were really interesting. It actually falls in line, Drew, with other utero studies. So when we look at what your mom ate in utero, how that impacts your microbiome. So that's kind of one thing that we look at, number one. Your mother's diet impacts your microbiome. Even even your mode of delivery, as you know, impacts your microbiome as well, right? And so like the microbial diversity, all of that, that has an impact. And we do go a little bit into gut health in the book. The other thing that we saw here is that when your mom had a less nutrient-dense diet, so a lot of processed foods, a lot of foods that didn't have a lot of nutrition,

you were simply more at risk for the condition, probably based on a cascade of all of these other conditions. So looking at the microbiome perspective, looking at just your blood sugar management, et cetera. So again, it really, it was not a study we were surprised to see, but we also weren't looking for it. Even though we've seen other studies looking at the connection between what your mom ate, mental health, et cetera. A lot of the connection here is really microbiome based, but it's also looking at your risk as you get into childhood, adulthood, et cetera. Yeah, and on that note, there is a recent study show that if the pregnant woman developed gestational diabetes, meaning diabetes that occurs during pregnancy, their kids, you know, there will be at greater risk to develop fatty liver later on in life. The mechanism of that is poorly understood, and it's probably multifactorial related to why they develop diabetes during pregnancy in the first place, genetic factors.

dietary factors, et cetera. But it's kind of, you know, it tells you the idea is like, you know, what happening in utero can affect technically the diseases that may happen later on in their life. You know, before we get into this next category, which is things that are within your control, which is really fascinating. And there's a lot of nuances that are there, some that we already touched on. Our show has a huge following on YouTube. We want to grow it, but there's 400,000 plus people that follow this channel on YouTube. And a lot of our audience, likes to watch this on YouTube. Now, I don't know if you guys know, but YouTube is the second biggest search engine in the world.

And sometimes when you go and search things, you go down all sorts of different rabbit holes, some that have good information, some of them that have bad information. If you search fatty liver and non-alcoholic fatty liver disease, some of the top content that's out there is explaining to individuals that there are warning signs like spots on the body, spots on the face, spots on the legs, things that are going on with your feet, that could be indications that there's something going on with your liver. Is there any truth to this out there?

Because I guarantee that some of the people that are watching today have come across some of these videos that are there. Honestly, the short answer is, well, one size doesn't fit all, quite frankly, but the short answer is no. You know, fatty liver disease is pretty much silent disease, like we said earlier. and it gives you non-specific symptoms such as fatigue, maybe foggy memory, which are non-specific symptoms.

A lot of things give you those kind of things. It may give you a little bit of pain in the right side of your abdomen, like non-specific tenderness, more like pain, associated with certain posture, when you sleep on your right side, you feel like, you know,

a little bit of tenderness on the right side of your abdomen. Those are scientifically proven, but in terms of rashes, somewhere than your body. Liver spots. People talk about liver spots. Not, no, not that's one.

So it's important because this gives us an opportunity to sort of educate the audience. Sure. Instead of trying to self-diagnosed by looking at your body, really you want to be going in for your routine blood work and testing. And of course, pick up a copy of your book because that's going to give people the guidance. Hopefully in collaboration with their medical practitioner. that they can start to work on making these changes in their diet, in their lifestyle, and their exercise. We're going to chat about that in a second. And don't go too far down the Google and YouTube rabbit hole of just, oh, something's going on with my feet. And so now I know

that I have, you know, fatty liver disease. It's better just get, you know, the routine medical work that's there. Krista, again, that's a thing. True. I was going to add this. So in addition to that, too, this is what I see a lot of on YouTube, is really this promotion of liver cleanses. So there's a lot of promotion of like, oh, you should have a liver cleanse. And here's how you can have one. Or you can buy this kit and it will be a liver cleanse for you. And I always tell patients that ask me about this like when they're like, oh, I'm going to, you know, January 1st, I'm going to do a liver cleanse, right? He was like, well, why don't we just take care of our liver all year round? And we don't need a cleanse, right? So we don't,

we don't really have the science showing that these liver cleanses do anything beneficial. In fact, they're either neutral or they can be really harmful. They can cause electrolyte imbalances, things like that. I know people that have wanted to get colonics to help their liver. So I think sometimes what I see in my patient face is this desire to kind of take the quicker route. I don't have it in me to change my diet right now, but I'm going to do liver cleanse and that's going to solve everything. So I think that's the other thing we always need to look at. Like, gosh, let's just look at this organ as something that we want to care for year round.

And then take the money that we're going to spend on that liver cleanse and go get some kale, right? Like go get something that, like, is a little bit more friendly that we have actual science to. You know, as part of being two people that worked there, almost their entire careers at Cleveland Clinic, not a lot comes out of our mouth without a bunch of science right behind it. So I think, like, that's one of the keys for some of these videos or some of these things that people are saying in any platform. What's the science? question the science and if the science is not there, then maybe move on to something that does have a little bit more efficacy. Yeah, that's such a great reminder. And it goes on both ends.

If you go to your medical doctor who has the best of intentions, but they're not up and up on the latest research that's out there, they may not know that there are dietary interventions that can actually get to the root issue of most cases of fatty liver disease. And on the flip side, there's a whole wellness, and I wouldn't even call it wellness industry. There's a whole industry that's out there that it's trying to prey on individuals by offering them quick fix solutions, liver cleanses, gut cleanses, whatever it might be. I'm sure some of them have some themes, especially if they're focusing on whole foods and getting people to eliminate out ultra-processed foods and calories from their diet.

I'm sure some of them have something good about them. but especially when it comes to one simple supplement or one simple pharmaceutical pill being able to get to the root of this, that doesn't exist, which is the perfect tee up for the things that are actually in our control, the things that are in our control as individuals. Now, even though we've been calling this non-alcoholic fatty liver disease, one of the first things that you do talk about is alcohol when it comes to this area. So, four people, you're going to be able to, so four people, you're that are and this word can be bastardized in different ways and everybody has a different term for it modern moderate levels of drinking everybody has a different level of what moderate means right

for people who have some regular inclusion of alcohol in their diet what do you want them to know about their risk when it comes to non-alcoholic fatty liver disease you know I think um dr. hannoneh brought this up at the very beginning of our interview we haven't talked about it but he talked about one of the roles of the liver to clear toxins and to convert toxins into something that the body can understand and is not going to, you know, really fall apart for and then get it out of the body. That's a great example of what the liver does for alcohol. So when alcohol comes into the body ethanol, the liver sees it as a complete toxin. It stops other processes in the body for the goal of taking this toxin out. So you're right. We all have a

difference definition of moderate. I know within my circles of dietitians, a lot of us even disagree with the CDC, with the Who and the American Heart Association guidelines for drinking. We just think having a drink every day might be a little bit too much. Maybe that's not moderate, right? But we can get into that at a different time. But just looking at that and then looking at the fact that you are putting a substance in your body that the liver has to do every everything in its power to convert and get out. And it taxes the liver. So even if you're in just the early stages, or let's say your fat and your liver is a normal amount, but you've got some other thing going on that might put you at risk somewhere down the line. You're still hitting

your liver with an insult. And so that's the way we really wanted to look at alcohol is whether or not you think there's some protective mechanism to the liver, it's an insult. It's really, there's no protective mechanism that we can see here. Dr. Hannanay could go into great more detail, but in the first few stages of the disease, we still do allow some moderate, again, very subjective, moderate alcohol consumption. But our goal is really, hey, listen, if you can go without alcohol, it's going to be better than having alcohol in the diet, regardless of what the source of alcohol is. And in your definition of moderate, are we talking about two or less drinks a week? Is that about, where do you, where do you suggest?

So for my patients, especially my female patients, which the bulk of my patients are, yeah, I will say two or less drinks a week. Typically, I will put it towards, hey, just have a drink on a Friday night, on a Saturday night, maybe, or maybe break it up a Friday and a Sunday. But I actually have my patients measure that drink. Because I think sometimes we'll say, okay, no, I just have one drink every few nights. But that one drink defined by the American Heart Association is, let's say, if it's wine, five ounces. Okay, so most of my female patients drink wine. That's five ounces. Take a five

ounce measuring cup. Okay, so measuring cup that has volume, put five ounces of wine in there and then put it in your wine glass, right? We have plenty of studies showing that the size and the shape of the glass can skew our understanding of how much is in there. So many of my patients have been drinking two glasses, two and a half glasses, and they just haven't measured it. So again, it's kind of like measure it out, get an eyeball of what that looks like. And, you know, and then you can start defining what your actual drink is per week. Yeah, I 100% agree with the question. And quite honestly, if I look at my practice, one size doesn't fit all.

For patients with fatty liver who have significant fatty liver, significant inflammation, fibrosis, scarring of the liver, the answer to alcohol is no. We did study when I was in Cleveland at the Cleveland Connect back in the days, where technically we looked into those patients with fatty liver, significant amount of fat liver, and we split them into three groups. Group number one, who consume significant amount of alcohol. They drink every day more than two drinks every day.

And clearly, they get themselves into trouble. They're more likely to develop more liver disease, liver cancer, etc. And then you look at the group who drinks social amount of alcohol, social amount, meaning they don't drink every day, and when they drink, they don't exceed one to two, compared to people who don't drink at all, zero, once they have fatty liver disease. And clearly, you will see that people who are social drinker with fatty liver, they're not as bad as heavy drinker, obviously, but they were at slightly increased risk to develop liver disease and liver cancer compared to those who don't drink at all.

So three lines, if you will, the excessive alcohol in trouble, no alcohol, they did the best and then the social in between. If you do have early stage fatty liver disease, meaning really fat you're very fat, you are not too bad, no inflammation, no scotting. I allow alcohol socially, you know. I love my glass of wine on Friday and Saturday evening, you know, I think it's reasonable if you don't have significant fatty liver disease at base on. That's great.

back to all the nuances that are here so that you can tailor a program to individuals that they actually will stick to. You stick to it. It's that consistency working with practitioners like yourself and other people in your network that actually leads to the results. The next category of item that you said that is within your control is gut health. Who wants to talk about the importance of our overall gut health and how that's connected to the liver? Yeah. So I, you know, gut health is another thing I was thinking about when we were just talking about alcohol, right? Looking at the disruption to the microbiome when we're drinking alcohol, even from moderate levels, right? We have some studies looking at that as well. So we did touch on the microbiome

microbial diversity. And really, it goes in line with looking at what are some of the things that insult the microbiome. So refined grains, simply not feeding our good microbes, the food that it should get to be able to flourish and proliferate. One of the things that I think we put in the book and that I say to my patience all the time is that if we think about our guts as a battlefield, we got the good guys on one side and we got the bad guys on the other,

if you feed the good army, the good army will grow. It will be diverse and it will be strong enough to overtake the bad guys. Feed the bad guys and the same will happen. So what we know is that sugar does act like almost this parasitic approach to the microbiome that feeds these bad microbes. Alcohol can do it as well. Refined grains can do it as well. So really, it's not as if fatty liver causes a huge

disruption of the microbiome. What we know is that if you're not focusing on microbiome, you'll be more at risk for fatty liver because of the fact that the gut is the second brain. and it has so much involvement in our overall health and our risk of development of other chronic conditions. That's super helpful. You know, there are certain studies that showed there are changes in the microbiome that happened as a result of excessive carbs and sugar intake, which make the microbiome producing the bad microbiome, if you will, that will take over, produce alcohol. produce alcohol. So yeah, you're not drinking alcohol,

but now the bad bacteria is producing alcohol and producing sugar. And that will lead, obviously, to liver damage. And that may explain why, you know, I see it all the time. You know, my patient tells me, I'm unable to lose weight. You know, I'm, you know, sticking to the diet, unable to lose weight. Well, because you have the microbiome, this bad bacteria, producing sugar, if you will. So you may not, you know, unless you change that microbiome, into a healthy one that produce good nutrients or digest the food in the right way,

you'll probably struggle to lose weight. We also know, Drew, no, you're well aware of this as well based on your work, but, you know, we all have a different fingerprint, right? So we oftentimes look at our fingerprints of our microbiome and what that looks like. So people with fatty liver disease that also might have central obesity might have a different fingerprint of their microbiome than someone that does not. And that's, you know, we still are learning about this. We still need more data, but that can also impact the risk as well.

Well, it leads to this bigger idea, which is that one of the key ways to take care of your microbiome is making sure you have a good diversity of different things. And so the level of daily fruits and vegetables that are incorporated, the healthy carbohydrates that we want everybody to have a good amount of because they come with fiber is one of the things that's in people's control. We're going to get to that list of 12, and we'll share a little bit more about them in a second. But do you want to just mention why our daily consumption of fruits and veggies is so key when it comes to supporting the liver? A big component here is going to be the fiber, which you mentioned. So looking at prebiotic fiber, we know that prebiotic fiber for ments creates short chain fatty acids and helps probiotics actually thrive, actually gives them food. So there's that one component. but it's as if like I look at patients that come into my practice and I'll just use kale as an

example and they say oh my diet's really good I ate a lot of kale what else do you what else do you eat outside of the kale well I just love kale you know that's what I focus on right so we talked about microbial diversity getting this assortment of different things the way I put it to my patients is really looking at getting different colors so instead of telling someone have seven servings of fruits and vegetables every day, which people are like, what, who's got that kind of time? If I tell you to have seven colors every day, that's going to make you think. It's going to make you stop, and it's going to give you that diversity. It's going to give you a diversity of nutrients because you're choosing different foods. So yeah, you might still have that kale, but also you might

have some berries or you might have a carrot. So now we've increased to two or three colors. So I really focus on colors. The Institute for Functional Medicine has this great fight nutrient spectrum list for kids. And I always joke that like, yeah, this is for kids. This works great for adults, right? Just click off your colors as you go through the day. Go through the grocery store. Put the colors in your cart. So what we know from the data is the more diverse our diet is, the more fiber, the more phytonutrients we have, antioxidants, flavonoids, carotenoids, the better our microbiome will be. So actually, we'll come back to these other couple of risks. factors, but you couldn't have teased it up better. Let's go into the 12 liver-friendly foods here.

As we are in the latter half of our interview together, this is a great thing to inspire individuals that there aren't many foods that they can eat that not only support their health and will help them love their body back, but are in particular great for their liver. And number one is really surprising on this list of 12. another one of these things that there's a lot of confusion about, and number one is coffee. What do you want to say about coffee? Yeah, we, I mean, Dr. Haddon and I and I spent about a year and a half combing through research before we even put pens and paper.

And coffee just kept coming back. It kept coming back in every single study looking at the bioactive compounds that coffee has and the benefit to liver. Now, not just general benefit to liver, but looking at liver-fi. which is when you start to get a little bit of scarring and inflammation in the liver and helping to reverse that condition. So much activity with coffee. And you're right, there's been a little bit of controversy, right? So when we look at studies, what we have found is that both caffeinated and decaffeinated coffee tends to be very beneficial to the liver. So really,

this pince points to us that it's the bean, it's the coffee bean, that has, the benefit. And where we go ahead and ruin coffee is when we were talking about earlier today, adding it to, let's say, a syrup or putting a whole bunch of, you know, whatever, a whole bunch of artificial things in our coffee to make it more sweet. And then it becomes a dessert. But black coffee, we know, is one of the greatest sources of antioxidants globally. It's probably because more people drink coffee than have broccoli. But there are a lot of compounds in coffee that we know help to reduce overall inflammation, including inflammatory processes within the liver. Yeah, I can't agree enough.

I mean, you know, speaking of cleansing, you know, every now and then, like we said earlier, you know, patient comes in is like, you know, what do you think of this plants and that herbs and this supplements? And I tell them, well, guess what? There is only one supplement, one cleanse that has been proven over and over and over in research to detox your liver, which is black coffee. Indeed, believe it or not, there is studies from friends, showing that the coffee counteract the impact of alcohol on the liver.

So, you know, for a glass of wine, cup of coffee, you know, you neutralize the effect, if you will, the bad effect of too much alcohol on the liver. What's the dose? Patients ask, or individuals ask like, you know, what's the right dose? How many cups of coffee? Well, of course, of course, too much of a good thing can be a bad thing. So, you know, coffee can increase blood pressure, may affect sleep habits, you know, it doesn't help with anxiety and stress and stuff like that.

I tell my patients typically two cups a day. Ideally, that's the right probably dose. Two, maybe three, if it doesn't affect your sleep or your anxiety or your blood pressure, two to three cups a day of a black coffee would be good. Can they mix it with cream or sugar? you know, ideally no, but, you know, it should be black. That's the ideal scenario. But if they can't drink black, not too many people like coffee, and not everyone likes coffee.

You know, if they want to mix it with something, that's not the end of the world. And I would add that for individuals that have had nutrigenomics testing and they find that they have some sort of genotyping with CYP 1A2 gene, which shows whether or not you are a fast or slow metabolizer of caffeine, that's another great way to assess. you know, how high is too high in terms of your dose throughout the day. I'm going to go through a couple of these and kind of mention some together, since I know we only have about, you know, 15, 20 minutes left over. Berries and Kiwis, you know, these fall into the group of foods that are both colorful,

going back to eating the color of the rainbow and the charts that the Institute of Functional Medicine has. We'll link to that in the show notes so that people can check it out. But why do you think that, or why do you say to individuals that these foods are supportive of the liver? Yeah, it's really based on the data. The research was very strong. There was a study that we had cited in the book looking at Kiwi consumption and some of the components, the actual compounds that were found in Kiwi actually helped to provide a protective mechanism to the liver. Berries in general, so we do keep that more high level. So whether it's blueberries, blackberries, whatever the case may be, any color of berries, we know that there is a lot of antioxidant capacity and the ability to reduce overall inflammation. Again, as we replace more fat with healthy tissue in the liver, inflammatory processes increase. So that is why kind of high level, having some of these foods can help to reduce that inflammatory process. This one might surprise some folks, but it's dark chocolate. What do you love about dark chocolate when it comes to the liver?

So dark chocolate, I often make this joke, and I won't bash any candy companies, but I haven't talk about the fact that a candy company will get a hold of the Coke, and just totally destroy it so that it tastes great, right? So dark chocolate, the more dark the better. The cocoa bean is very similar to the coffee bean and that it's got a lot of flavonoid components, a lot of compounds that we know reduce inflammation that we know can actually help with reduction of fibrosis in the liver. We've seen this in some of the studies.

I think the key here is what percentage of dark? So we tend to aim about 74 or greater percentage of cocoa content. A lot of times you'll see a dark chocolate bar in the store. It will say dark chocolate. I always tell my patients, go ahead and call the company and find out what the percentage of cocoa is. Because it only has to be 51% to be called dark. But we don't see that same benefit with 51%. So the darker, the better, but we also want it to be palatable.

Once we get into baker's chocolate, 100%, it's kind of gross, right? Like take a spoonful of cocoa, put it in your mouth. Great benefit. You're not going to keep that habit too long. It's just not so tasty. Good luck swalling it without gagging 100%. That's not happening. You know, we skipped over this one, but I'll put two together here.

Edomame, and even though it's not a legume, let's talk about edamame and legumes. Those are also on this list. Yeah. So edamame has, I feel like edamami is really misunderstood, and that's because of the soy component. But we do know that the isoflavones that we see in soy do help with overall liver health. We also know that in female patients, that isoflavones can help on a whole variety of other indicators can help with looking at even reduction of risk of certain breast cancers or breast cancer recurrence. And that's where soy is very misunderstood. I think a lot of times, you know, we talk so much about food.

And a lot of times what happens is we get a bar or something and it has a soy isolate. So this is why we are promoting something like pure etamame, like we would see. consumed in Asian countries where we have the benefits of reducing inflammation, reducing some of these indicators that are risk factors for fatty liver, and we don't have as much risk as people think. So soy is really misunderstood, and that's why we wanted to make sure it was included here. If we compare that to legumes, obviously, to very high fiber sources of protein. So now we have the protein component as well and the fiber. So any plant is going to give you, fiber, but beans and legumes tend to be a little bit on the higher side of it.

I'm going to just mention a couple that we kind of talked about a little bit earlier. And if there's any one of these, you want to tease out individually, great. But just because there's a few other questions that are here, I'm going to kind of cover them a little bit high level. So you did talk about the importance of cruciferous veggies and how important that they are, especially when it comes to women's hormonal health, right? But even for men and women, how important these cruciferous veggies are when it comes to just the natural supportive detoxification process,

sulfurophane, a lot of other beautiful compounds that are inside of that. Nuts and seeds, we kind of chatted about a little earlier. Is that primarily the fiber and the protein? Anything else you want to mention about the nuts and the seeds? It's also the healthy fats as well. So, you know, that's kind of twofold. So nuts and seed have healthy fats, obviously. So they got mono-unsaturated fat, polyunsaturated fats.

But they can also serve as a really palatable replacement. for some of our patients that are really struggling with some of their snacks and things like that. And the other thing with fats, I mean, fat, I don't feel like it's like this as much anymore, but it used to get such a bad rap. And what we know is that fat is very satiating. So when you have fat, it keeps you full or longer. And so as we're asking people to potentially in any one of the plans, reduce some of their overall net carbohydrates,

adding in something that's really pleasurable like nuts and seeds can really help them kind of get over that hump. You know, one that was on here that might be a little bit surprising to folks is you had chicken, turkey, and fatty fish, right? Let's talk about those protein sources and why you guys are such a huge fan of them when it comes to feeding the liver. Yeah, so we know that, again, protein sources can be a great alternative to some of the higher carbohydrate options that we might have. If you're getting into a really stringent low-carb approach, then maybe the beans and the logooms won't work as great, but the protein sources will from an animal-based approach. Omega-3s really stands on its own. You know, I was listening to the podcast you just did on Omega-3s,

and it was absolutely fascinating, but so in line with what we found with the liver. So we've seen studies looking at either supplementation or Omega-3s, DHA, and EPA derived by, fatty fish from the marine source and really looking at the reduction of some of the not only fat contents, but also some of the inflammation that occurs within the liver once we start going to some of those latter stages. So I think it's really kind of trying to promote more of that protein and the importance that protein plays. But the fish has a special factor given the DHA and the EPA content of it and the inflammatory benefits that we see with. EPA and DHA.

And if I may add that some of these nutrients also, the rich in vitamin E, which actually has been proven in a study publishing the New England Journal of Medicine, that decreases inflammation in patients with fatty liver disease. So that's additional benefit. So I covered a lot of these 12. I didn't cover them all, but that's partly because I want the audience. Pick up the book. It's out.

It's available. If it's not available, you can still pre-order it. That's the best way to guarantee that it's on its way for you. The link is in the show notes. I still have a couple questions here, but I do want to give a shout out to the book. Regenerative Health, discover your metabolic type and renew your liver for life. There's plenty of fantastic food breakdowns in there. The complete list of 12.

There's also the pathway of how do you actually begin to turn this into a plan to get your metabolic health under control so that you can actually start to make a difference in your diagnosis of either pre fatty liver disease. That's not really a thing, but it really should be a thing, that you're well on your way to getting fatty liver disease. And of course, people that have full-blown fatty liver disease, non-alcoholic. Now, a couple more things here that I see that are top questions from our audience when it comes to this topic is, what are the roles, if any? Although we know that there's no quick fix supplement that's out there?

Are there baseline supplements that people can be thinking about that can support their process of healing and supporting the liver? Yeah, so I would say from my perspective, the omega-3s are one that I would definitely recommend to my patients because of all the reasons that we just talked about. Vitamin D can be really useful as well, a general multivitamin that someone might have a few days a week. And the other thing I recommend to my patients would be probiotics. So looking at either probiotics or a combination of probiotics and prebiotics, especially if you feel you're really struggling with changing the dietary approach, really just to try to give your body a little bit of a jump start and being able to heal the microbiome, which, again, is all part of the digestive system that the liver is from as well.

I think a lot of my patients come to me and Dr. Hannanay could talk a lot more about this, but wanting to take milk thistle and dandelion. And really, we don't see data showing that these things are really incredibly effective and definitely not any more effective than the dietary approach or even looking at something like an omega-3 supplement. Yeah, I 100% agree. There's not a day that goes by without mentioning milk-sizzle patients. you know, mentioned it in the clinic all the time. And I wish it works.

I really does wish it does something, but unfortunately it doesn't do a lot of benefits to the liver. I don't think it's harmful, but it's just not going to do much. In terms of supplements, I agree with everything Kristen said, and I add coffee, which we talked about extensively earlier, and then perhaps vitamin E. Although the thing with vitamin E, you don't want it. do it long term. You don't want to stay on vitamin E, particularly at high dose for a long period

of time, but short term of vitamin E to detox your liver, decrease inflammation until you change your diet, lifestyle, et cetera, and get rid of fatty liver may be very reasonable. You know, as our audience is thinking about all this fantastic advice that's been given, and they're connecting all the dots and they're understanding that this is not a lifelong sentence, you know, being in a position where you're on your way already have non-alcoholic fatty liver disease, except for, again, as we mentioned, in these rare stages where you're at the very end stage of it, it's not a lifelong sentence. They can reverse it. They can treat it through dietary and lifestyle interventions. As they're thinking about putting all this information together

and they're thinking about going down this journey, what are some final words that you want to leave them with when it comes to this space for whoever would like to start first. You know, one of the things that I think is really important is this book is about the liver, but if anyone has any abnormality from a metabolic side, then this book is for you as well. Whether you have nothing wrong with your liver, we'll go back to what you said, Drew, which I love, which is like pre fatty liver, kind of like, that's just like I got that in my head now. but it's really for anyone that is struggling with belly fats, anyone that's struggling with insulin resistance.

You know, I think that sometimes the liver just seems like, oh, gosh, like all I keep hearing is that we got a long time before anything really bad happens. So what I want people to know is that this is really the population that can really benefit from this is much greater than just someone who's been diagnosed with fatty liver disease. you know, it really looks at the bulk of us that are challenged with some of these issues that we're having. And I think, you know, what we really tried to do was provide approaches that, as Ibrahim said so well, fit into our personal preferences or cultural, our religious preferences, provide that flexibility, not have that stringentness, but provide something where someone can say, gosh,

there's so many different ideas here from a dietary perspective, I really like these three. And those are the three I'm going to grab on. Yeah, I mean, this book is not just about treatment and reversal of fatty liver, but also about prevention. So even if you do not have fatty liver disease about how to prevent it from happening in the first place. Remember, like we said earlier in the interview, this is a very common problem. One in four people out there have fatty liver disease. And it's silent disease. It doesn't have symptoms until it's late in the game.

And we don't want to wait too late. and that's, I think, the key is if you or your loved one or friends, family, have risk factors, belly fat, 5-2 diabetes, high blood pressure, etc., then, you know, you might want to bring fatty liver to the attention of your physician. Find out if you have fatty liver and find out how bad it is and what can I do to prevent it or stop. Fantastic. Well, thank you so. much both of you for sharing these incredible words of wisdom. I'm so thankful for long format podcast. And I know you guys have been on a bunch of them and you're going to be on a bunch of them because as I mentioned before we started recording, you know, for the person who's listening who's struggling with their health, they're not getting the download of this information.

They're not always getting access to it. And that's where social media and, you know, the internet is actually really supportive and can be a beautiful silver lining in people's lives, even if they do have a diagnosis or if they have a family member that has a diagnosis and they're worried about their own health in the future, they can get quality information from individuals like yourself and actually feel, you know what, I do have agency. My life is in my control to largely their control and that I can do something about it. And your book is a big part of that. We're going to link to it in the show notes below. Again, please pick up a copy, Regenerative Health, Discovered, your metabolic type and renew your liver for life.

If our audience today wants to keep in touch with you and follow along on your journey to get to the root of this silent epidemic, how should they be following the two of you? Kristen, do you want to start? Sure. You can go to my website, which is just my name, Kristenkirkpatrick.com, Kristen spelled with an eye. Or, of course, my socials are all fuel well with Chrissy. When you feel well, you feel well.

and that is all part of the process of better self-care and better health. Yeah, and for me, I work in Minneapolis, Minnesota, with a group called MNGI, Minnesota Gastroenterology. I also on the social media, Facebook, Instagram, you know, et cetera. So I'm going to hear today. And, yeah, I look forward to hearing. And also, because I know people are going to ask, are the two of you seeing patients right now? Are you open? Can people reach out if they want to get some.

support on their journey of getting to the root of their chronic disease? Yeah, definitely. I mean, I probably answer and work with some people over virtual, over email, at least three to four emails every day for people that read skinny liver and are still kind of working towards really benefiting their liver and just really interested in what some of the new research is that we have and how that can help them. Yeah, I'm practicing in Minnesota. Yeah. You don't want to come here in the winter, but, you know, that's what I'm.

Well, thank you both again. It's a fantastic book. It's a fantastic message of hope. And truly together, you two are on the path of changing the course of at least what's possible. You know, it's going to take all of us, including the audience who's listening today, which is why I always ask that if you know somebody who's struggling with this, at a minimum, send them this interview or send them the social media of these two lovely guests that on the podcast today. And if you want to go one step further, when you're buying your copy of the book, pre-order the book, and get a copy for a friend. There's nothing like a book that you can give to somebody that has the opportunity to change their lens of what's possible for them in their life.

Kristen, Ibrahim, thank you so much for being on the podcast today. I super appreciate it. Thank you. It was an honor. Yeah. Thank you, Drew. It was an honor. Indeed. Hi, everyone. Drew here. Two quick things. Number one, thank you so much for listening to this podcast. If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me. And it's the number one thing that you can do to support this podcast is share it with a friend. Share with a friend who would benefit from listening. Number two, before I go, I just had to tell you about something that I've been working on that I'm super excited about.

It's my weekly newsletter. And it's called Try This. Every Friday, yes, every Friday, 52 weeks a year, I send out an easy to do. digest protocol of simple steps that you or anyone you love can follow to optimize your own health. We cover everything from nutrition to mindset to metabolic health, sleep, community, longevity, and so much more. If you want to get on this email list, which is, by the way, free and get my weekly step-by-step protocols for whole body health and optimization, click the link in the show notes that's called

Try This, or just go to Drew Perot.com. That's D-H-R-U-P-U-R-O-H-I-T dot com and click on the tab that says, try this.