I am honored to have Kristin Kirkpatrick joining me today. She is a registered dietitian, bestselling author, presenter, and dietitian with the Department of Wellness and Preventative Medicine at the Cleveland Clinic.
The fatty liver epidemic now affects one in four people globally. In our discussion today, we explore who is most at risk, the essential functions of the liver, and how factors like COVID, stress, overeating, and alcohol contribute to the problem. We dive into the role of visceral fat, and Kristin shares her go-to labs and tests for assessing metabolic health. We break down why SECO is outdated, why sugar is particularly harmful to the body, and the effects of andropause, menopause, and other hormonal changes. We also tackle the toxic diet culture, under-eating, alcohol, poor sleep, exercise, carb restriction, beneficial supplements, and how nutrigenomics can guide us in navigating bio-individuality.
I know you will love this eye-opening conversation with Kristin Kirkpatrick.
IN THIS EPISODE YOU WILL LEARN:
Why fatty liver is a silent epidemic
The connection between fatty liver, type 2 diabetes, and insulin resistance
How the COVID-19 infection impacts the liver
How non-alcoholic fatty liver gets diagnosed
What are the primary functions of the liver?
How ultra-processed foods contribute to sugar intake and impact metabolic health
Why we must nourish the body with nutrient-dense foods instead of focusing on calorie restriction
How does aging affect metabolic health?
Why it is essential to maintain muscle mass during menopause
The role of exercise in maintaining metabolic health
How nutrigenomics helps in understanding genetic influences
“Alcohol can lead to increased insulin resistance because belly fat is a lot harder to control, especially if you are perimenopausal or postmenopausal.”
-Kristin Kirkpatrick
Connect with Cynthia Thurlow
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Submit your questions to support@cynthiathurlow.com
Connect with Kristin Kirkpatrick
On her website
On social media: @fuelwellwithkrissy
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Kristin Kirkpatrick. She's a registered dietitian and bestselling author, presenter, and a dietitian with the Department of Wellness and Preventative Medicine at the Cleveland Clinic. Today, we spoke at length about the fatty liver epidemic, the prevalence of fatty liver that impacts 40% of the population, one in four worldwide, those who are at greatest risk, the impact of COVID, stress, overeating and alcohol, the major functions of the liver, which we refer to affectionately as the gatekeeper of homeostasis, the impact of visceral fat and key labs and testing that Kristin likes to look at to evaluate for metabolic health, why SECO is outdated, why sugar is so highly toxic to the body, the impact of andropause, menopause and hormone shifts, the role of a toxic diet culture that contributes to this, as well as under-eating, alcohol and poor sleep, the role of exercise, carb restriction, key supplements that can be beneficial, and the role of nutrigenomics as it pertains to navigating bio-individuality. I know you will enjoy this conversation as much as I did recording it.
[00:01:42] Kristin, such a pleasure to have you on the podcast. I've been really looking forward to diving into this huge issue that many people are not even aware of. Why is fatty liver this silent epidemic that most patients are unaware of? And I would argue that most clinicians are not talking to their patients about.
Kristin Kirkpatrick: [00:02:02] Yeah. I think it's a silent epidemic because of the fact that we take the liver for granted, right? We don't think about it. We just are like, “Hey, it's going to do its job. I was born with this.” Many of my patients think it's just supposed to detoxify when you drink alcohol and that's about it.
[laughter]
[00:02:20] But it is a silent epidemic for two reasons. Number one, it is really paralleling what we are seeing in the incidence of type 2 diabetes, insulin resistance. When you look at an individual that has that, there should be this light bulb that goes off that, “Hey, let's check the liver as well, because there's probably something going on there.” So that's number one. Number two, the liver is so resilient, it takes a punch, it takes a beating, it's not going to start screaming when it doesn't feel too good. It's really going to go through the process of damage and really not wait until the end game to be able to start giving some really meaningful warning signs. So, we just don't get the warning signs, which is why we just don't think about it.
Cynthia Thurlow: [00:03:03] Yeah. It's interesting to me because when I was going through your book and refamiliarize myself with some of the statistics, so for anyone that's listening that's not familiarized, we used to call it non-alcoholic fatty liver disease. It's kind of having this evolution in terminology, but what's interesting is the prevalence is 40%. So, 40% of individuals listening to this podcast or their loved ones and family and friends are directly impacted by this. It goes directly along with this metabolic health crisis that we're seeing. And for anyone who's listening who thinks, I need to ask for specific testing. There's so many things that we can do to unwind. Our liver is incredibly resilient, thankfully, but one in four worldwide are impacted by this. The prevalence being 40%, most if not all of us are going to be directly impacted by it.
Kristin Kirkpatrick: [00:03:53] Yeah. In some way or another. I tell people that like, “When you walk to the mall or you go to Target today, probably every third or fourth person that you pass has some sort of degree of fatty liver.” Now, we don't know what the degree is. It could be minor, could be major, but think about that. Just put that in your head that of all the people you're going to pass today, a lot of them will have an abnormal accumulation of fat in the liver that could be impacting not just the liver, but their entire health.
Cynthia Thurlow: [00:04:22] It's so interesting to me in many ways because this is not an issue that we're just seeing in adults. Also now, seeing this like, when I trained as a nurse and a nurse practitioner, seeing type 2 diabetes in a child was almost unheard of. Post pandemic, we're seeing more metabolic health issues, but we're also seeing chronic inflammation and type 2 diabetes in children as well. And so whether or not you and yourself are directly impacted, we need to be thinking about our younger populations as well, because it's quite significant if a child or a young adult is impacted by fatty liver, because it means it's been something that's been brewing for many years. Now when you're working with patients and you're talking about lifestyle, what has been your experience when we talk about the impact of COVID. I know this is now four years ago from when the pandemic started. I'm sure you saw a lot of patients with stress eating because so many of us had never been through this before. How has that impacted their liver health quite substantially?
Kristin Kirkpatrick: [00:05:22] Well, we know that COVID infection in and of itself and the inflammatory process that occurs could of course, impact the liver. But from that lifestyle perspective, what I saw with my patients is many of my female patients in particular started going towards that daily glass of wine. That's one thing I noticed that drinking went up pretty substantially. Now, of course, non-alcoholic fatty liver disease is not about alcohol, but we do know that excessive drinking, and we can define that in many ways. We could talk about that, Cynthia, for an hour, whether or not our government standards of a drink for a woman every day are appropriate. But having a drink every day in my female population was not just having a drink because my patients were not having the 5 oz. They were having like 10 oz and calling it a drink with dinner.
[00:06:12] And so what that then leads to is disruption and sleep. It can lead to poor hormonal health, it can lead to increase incidence of insulin resistance, because now belly fat is a lot harder to control, especially if you're perimenopausal or postmenopausal. So drinking for sure, but then snacking, just being in our home base just increases the risk of snacking because we're so close to the kitchen. I know it sounds ridiculous, like, “Oh, just being close to the kitchen means you're going to eat.” Yes. We have some data showing that just passing that kitchen multiple times a day makes you more likely to eat something. We did see that lifestyle perspective that then when COVID was over, many of my patients said, “Hey, I really don't want to have that glass of wine. I really want to kind of curb that. Can you help me with that?” I did see a huge incidence of that.
Cynthia Thurlow: [00:07:04] Yeah. It was interesting, during the pandemic, there was so much that we could not do. But my husband and I did a lot of walking with our dogs. And when it was recycling day, it was amazing to see, and I say this non pejoratively, just observationally, how many empty wine bottles were in the bins for recycling? And admittedly, women and men have discussed this very openly that out of frustration, depression, whatever cascade of symptoms they were experiencing, that alcohol was an easier thing to utilize because it's so accessible and so helping people understand that alcohol can lead to, as you appropriately said, the poor-quality sleep, disruption in REM, cortisol, or dietary choices. I always say, when you don't sleep well, you don't make good dietary choices, etc. Let's pivot and talk a little bit about what are some of the key hallmarks of liver function that maybe people, as you appropriately stated, they think about the liver in terms of, I drink alcohol, my liver helps me process it. What are some of the other aspects of liver that you think are really high level and important for individuals to understand?
Kristin Kirkpatrick: [00:08:15] Yeah, I think your metabolism of nutrients is a really big one. I think that when we think about metabolism of nutrients, many of us think about it from a very elemental way that, I eat an apple, and that apple goes to the system, and it get absorbed somewhere, and then that's the end of it, and hopefully I grab all the vitamins and minerals, etc. But it's much more complex than that we know that, right. A lot of that is dependent on your microbiome, a lot of that is dependent on the bio-availability of the actual food you're eating so there's a lot that's going on there. But the liver plays a role in metabolism of simply the nutrients that come from that apple.
[00:08:50] So if your liver is not functioning, then you might not grab all the nutrients that are coming in. The liver also plays a huge role in blood sugar management. It's oftentimes the last organ we think of. Maybe, we'll think of the pancreas and we think of insulin. But what happens is the liver is really kind of the gatekeeper of homeostasis, right? Homeostasis being what is the normal state of your body. And so it is there to detect, “Is your blood sugar a little too low, is it a little too high?” And then try and alter things within the body, basically act as a director and give direction to other organs. “Hey, blood sugar is a little too low. Let's increase it or we don't have enough glucose here, so let's make glucose out of protein, amino acids, gluconeogenesis.”
[00:09:36] So it plays a huge role in that as well. It does play a huge role in detoxification. So, yes, we think about alcohol, but really it's thinking about walking down the street. Are you living in some place where there's a high level of pollution? Do you get dry cleaning? And then you keep it in the plastic, and it's just kind of sitting in your kitchen for a while and you're walking by it every day? Are you eating fruits and vegetables that have a high level of pesticide? The liver is responsible, the sole responsibility, really from any other organ to say, “Okay, this is not something that's good. I need to put this in a state that I can understand, then I need to get it out of the body.” So the detoxification is really important because once our liver health starts going a little downhill, that process starts going downhill as well. So now we have the inability, let's say, to take away some of the toxins that are in the body that the liver normally took care of. So, I would say those are three huge things that the liver is responsible for. But at the end of the day, I always say, “If your liver is not working, nothing is working, nothing.”
Cynthia Thurlow: [00:10:40] No and it's a very forgiving organ. Oftentimes, it takes a lot for the liver to stop functioning in an optimal way. And when we talk about detoxification, I think, unfortunately, this term has been bastardized. There is a normal detoxification process in our bodies that is designed to be optimized. There's two phases in the liver. There's one in the gut all very important. If any of that is disrupted, it can impact-- phase 1 is helping you get toxins broken down into water soluble byproducts so phase 2 can take over. It's interesting, there can be a lot of genetically mediated reasons for why detoxification is not working effectively. But we know that our lifestyle certainly plays a huge role. From my cardiology background, I think a great deal about the liver being involved in clotting. We used to see a lot of patients in the ER and then also in cardiology clinic, and we could sometimes assess the degree of dysfunction in the liver based on, “Can they still clot their blood?”
[00:11:41] And for anyone listening, this can be catastrophic. If you cannot clot your blood, you can bleed to death effectively. I think for a lot of other people just understanding that this miraculous organ that gets not a ton of respect until it's not functioning optimally, has a lot of roles within the body that are really important to have optimized. Now, when we're talking about liver dysfunction, there's varying degrees of dysfunction that goes on. At the extreme is obviously liver cancer and cirrhosis. I'm sure we'll talk about that. But let's first start with non-alcoholic fatty liver disease. For most people, they're asymptomatic in my clinical experience. How are we diagnosing this? So, for the benefits of listeners, what are the first things when you're working in conjunction with other clinicians, what are you looking at lab work diagnostic wise to help assess this?
Kristin Kirkpatrick: [00:12:34] It's interesting. I've been integrative medicine at Cleveland Clinic for over 20 years. And I'm so lucky that I have access to these minds within integrative medicine, the one thing that I see over and over again is this huge attention to hemoglobin A1c, fasting glucose, as kind of the primary markers of, “Should we also look at something related to the liver?” Typically, our physicians will go ahead and run a full panel so we can see what's the ALT, what's the AST? Those are common liver enzymes that might be tested. Are those elevated? So that might be some warning sign as well. But the blood sugar is a huge one, because what we know is that individuals that have dysregulation in blood sugar. So even if that's just prediabetes and not full-blown diabetes, based on hemoglobin A1c, what we know is that there is probably about a 90% to 95% chance that there's dysregulation in the liver as well. So that's really a key hallmark there. The other key hallmark could just be looking at waist size.
[00:13:36] Let's say we have someone whose metabolic health looks relatively good, lipids could be the high end of normal, but they're normal from a laboratory standpoint. But the belly is higher than it should be, that's another marker we'd look at. So, for a woman over 35 inches, for a man over 40 inches, it sounds so simple. But when we carry in the belly, that's close to organs, that's really close to the liver. So, it does have a lot more risk than when we carry in, let's say, the thighs, the butt, that kind of thing. So, I would say those are two big things. If you have someone who is really struggling with belly fat, struggling with blood sugar management, those are key markers for us to say, “Okay, we got to get that under control, because probably there's something going on in the liver as well.”
Cynthia Thurlow: [00:14:22] Yeah. I think those are really practical things that everyone listening, very likely and presumably has had triglycerides, HDL. They've been able to look at those ratios. Fasting glucose, A1c, fasting insulin, and being able to check waist circumference, I mean, that is part of that metabolic syndrome piece. We're not even at the point where we're saying, “Go get a bioimpedance scale or go get a BOD POD.” We're talking about things that most people have a scale in their house. Most clinicians are drawing these labs. They can definitely be an indicator that you are potentially heading in the wrong direction, and especially with visceral fat. Why is visceral fat so significant vis-a-vis when we're looking at this metabolic syndrome, fatty liver issue?
Kristin Kirkpatrick: [00:15:06] Yeah. Because visceral fat is really deep within. Deep within the belly, and that's the closest amount of fat that is to the organs. Subcutaneous fat is going to be on the edge of it, and we don't want that either. But visceral fat is really where we see more cytokine activity, more inflammation. And you're absolutely right, I look at all these people are saying, “Oh, my gosh, I need to go get a DEXA scan and I need to go get all these things.” I'm like, “Why don't you pull out that pair of jeans that you've been trying to get into?” [Cynthia laughs] I always joke like I probably have three pairs from college at the back of my closet. Most people have a pair of pants that they're really struggling with. But that pair of pants, all jokes aside, is a great indicator of whether or not you're being successful or you've put weight on. If we get to the point where we feel like, “Oh, my gosh, I can't really button this up the way I used to.” You're going to get a combination there of visceral fat that has been brewing for a long time, in addition to the fat that's just on the surface.
Cynthia Thurlow: [00:16:05] I think for so many women in particular, we have a greater propensity for subcutaneous fat. Sometimes that's the fluff that we find frustrating. That is very different than this deep visceral very inflammatory-- It is really its own organ. It is such a sophisticated organ. It is not just fat and helping people understand the differentiators. Now, when we're thinking about, the role of lifestyle and how things are impacted, I know I asked this question of almost every guest because I think it's so significant. Certainly, as a registered dietitian, I'm sure you would agree. I think we as clinicians have in many ways misunderstood, bastardized the concept of calories.
[00:16:51] Now, it's not the calories are irrelevant, but it's one of many pieces as to why patients will experience weight loss resistance or have plateaus. What are your thoughts on the concept of calories in, calories out? Which is, I always apologize for this, but when I was a new nurse practitioner, that was the prevailing philosophy, eat less, exercise more. That alone would be the deterrent to further weight gain. What are your thoughts around SECO and other contributors to why we become weight loss resistant?
Kristin Kirkpatrick: [00:17:22] Yeah, it's interesting. I tell my patients that when we focus just on the quantity of calories, we stop caring about the quality. So if you're looking at, okay, calories in, calories out approach, and we go back to old thinking, which shockingly, some people, that's still the current thinking that we see from clinicians saying, like, “Hey, just eat less, move more.” That that's still being said. But when we think about this concept of, “Okay, just have little less calories.” What we see from the studies, what I've seen from many of my patients is, it doesn't really matter where those calories are coming from. It's almost like, “Okay, well, if I'm going to have 1200 calories, I'm going to have this chocolate bar for lunch because it still fits within my calories.” I got this allotment, right.
Cynthia Thurlow: [00:18:07] I think it's my macros, mm-hmm.
Kristin Kirkpatrick: [00:18:09] It's my macros. So yes, calories are important. We don't want to say that calories have no bearing at all, because we do know they do. But when you think about like a carbohydrate insulin model, what we know is that it is the breakdown of those calories and what happens specifically in this population to blood sugar that makes the most difference. So, if you have a low amount of calories, but those calories do not contain any fiber and they're very high in the glycemic load, you are looking at a day where your blood sugar is going to be consistently up, down, up, down, you're going to look at a rollercoaster-type approach versus peaks and valleys if you are eating foods that are a little harder to digest. So I think there's that perspective as well.
[00:18:56] The reason that a low-calorie diet typically doesn't work, and we're clearly talking outside of individuals taking a GLP-1 agonist drug because there's different mechanisms occurring there. Let's say you're not on these drugs, you're doing a low-calorie diet, you're bound for failure because the satisfaction level will never be met. And so eventually, again you're not being filled up, you're just kind of giving yourself these empty calories, your blood sugar is crazy. And so we know that when blood sugar drops, what do we do? We try and get it to go up again. And so the means to do that is let's have more sugar, let's have more high-glycemic load foods that then disrupts our ability to be able to consistently lose weight. We start yo-yoing a lot more, low-calorie diets are more associated with yo-yoing and we just don't have that satisfaction. I don't know a lot of people that say, “Hey, I'm on a 1200-calorie diet and I'm the happiest person on earth.” [Cynthia chuckles]
[00:19:51] And I think sometimes we forget about the happy factor with food and we've looked at everything else, but we take away this whole concept of like, “Yeah, I really love that food and I'm happy when I eat it. So, I think food is so ingrained in us in so many different ways. It's obviously part of every social situation. Our childhood determines a lot of it, of how we eat. So I just think calories can't be what we're focusing on. It's got to kind of be off in the background. We also know that typically when you're eating foods that are much harder to digest, consequently, you end up having less calories anyway because you can only fit so much in.
Cynthia Thurlow: [00:20:30] I think it's so interesting that we've had this evolution. I think for those of us that, “Maybe we trained in that SECO calories in, calories out model and we've come to realize there's multiple things that contribute.” And I find for most of my patients, when they're eating more nutrient-dense foods, and by that, I mean less ultra-processed, they tend to be more satiated. That's a direct byproduct of stretch receptors in our stomach and communication, if it's not impeded between our brain and our gut, versus the ultra-processed foods that are designed to be as addictive as possible, it is not a lack of willpower it is food science. There are food scientists that, they sit in a lab and they bring in outside people to guinea pig them and look at bliss points, “How much sugar can I add to a product to make it as addictive as possible, but still consumable?”
[00:21:22] And I guess what I found interesting when I was reading your book, you bring up that the average American eats 30 teaspoons or a half a cup of sugar daily. That's average. And I want everyone to just think about that, go into your kitchen and take out a half a cup of a measuring cup, look at that, and understand that is how sneaky sugar is in our diets, that our palates have become so attuned to this and how that impacts our food choices, our lack of satiety, our inability to lose weight, our poor metabolic health. It's interesting, the other study, or other statistic that really stood out to me was in a 2021 study, 57% of food came from ultra-processed foods. I've seen as high as 70% and it was worse for kids.
Kristin Kirkpatrick: [00:22:06] For sure.
Cynthia Thurlow: [00:22:08] If our kids are starting off addicted to ultra-processed foods, it makes me fear for their trajectory of their health throughout their lifetime.
Kristin Kirkpatrick: [00:22:17] Yeah. And I think, you used such an accurate word here, and that was sneaky. The half a cup is not coming in from what we always consider the traditional means. I mean, yes, of course, in some cases it is, but it's like, I have patients that say, “A half a cup, that's ridiculous. I don't have any soda. I don't eat any candy.” But you're right those ultra-processed foods. You're not looking at how much sugar is in your bread, how much sugar is in that cracker that you're eating, so it is. It's how it gets delivered. It's not always a traditional sense. It's not that we're all sitting around eating licorice all day. Some of us are, but that's not the norm. This high amount is coming in from other sources that we don't even recognize as being considered a high sugar food.
Cynthia Thurlow: [00:23:03] Yeah. And it's seemingly so benign. I think about condiments and salad dressings, and my oldest just left for college in August and having to have conversations with him about navigating food choices. Thankfully, he's at a university where there's a lot of options, but it's his first time living away from home, being in an environment where he's making all his own food choices. He's already said to me more than once, I can eat just about anything, but if I start drinking soda, it's all over.
Kristin Kirkpatrick: [00:23:31] Yeah.
Cynthia Thurlow: [00:23:33] He doesn't feel good. He said, “I just feel like I'm constantly hungry.” And so just encouraging the young adults that their parents might be listening to this podcast. Hopefully we've embedded enough good discussions and good education in them prior to them leaving the nest, so that they can continue making good choices moving forward. Although I'm a realist and I know there will be things my kids will eat when they leave the house that I'm going to have to just turn around and pretend I didn't see it.
Kristin Kirkpatrick: [00:24:01] [laughs] Right. As their parents, of course, and I think about this, I have two small boys. It's so interesting whenever parent comes to me and says, “Oh my gosh, help my child.” And that child is under the age of like, let's say 15. “Oh, my child eats awful and my child is obese and what can you do to help my child?” I always say, “Well, let's start, you and I, for about four or five months and then we'll see if we actually need to meet with the child, right?” Because the influence that our parents play with our food choices is huge, it's huge. So, I think that's a really important piece of it. We try to set them up with full knowledge that, yeah, they're probably going to have some foods that aren't the best, but it's not the 10% of the time when we have something that's not the best, it's when that 10% turns into the 90%.
Cynthia Thurlow: [00:24:46] Yeah, that's absolutely true. For anyone who's listening that has a teenager or young adult, everything we're doing with them as they are growing up, they are paying attention, they are witnessing what we are doing. And ultimately, I said to my now 19-year-old, I have to hope that, especially as a parent of a child with food allergies. Hopefully, you have learned through all those years of being conscientious. We actually went to dinner with him on Saturday night and he had protein and a vegetable. And I was like, “Don't do this on my behalf, do this because this is what you want to eat.” He was like, “Oh, I absolutely want to eat this.” I said, “Great.” Now, who knows what he does when he's at his dorm?- [Kristin laughs]
[00:25:23] -but having said that, he ate a really good dinner when we took him out for parents’ weekend. Now I'm sure over the course of your career, you've seen a lot of changes that go on, not just in men going into andropause, but women in navigating perimenopause and menopause. What tends to be some of the more challenging aspects as you working with your patients around this timeline. I definitely have key themes that seem to stand out, but I'm curious to share. I'm curious to see if these are the same things that you're experiencing as a clinician, talking to them about nutrition and frequency of meals, etc.
Kristin Kirkpatrick: [00:25:58] Yeah. I think the frequency of meals is really important because I have this common theme of patients that are in this stage coming and saying, “I eat nothing and yet I can't lose a pound or I eat nothing and yet I continue to lose weight. So how is this possible?” And then comparing themselves to their 21-year-old self, where if you just drop a few calories over the weekend, you drop a jean size. [laughs]
Cynthia Thurlow: [00:26:25] Yeah.
Kristin Kirkpatrick: [00:26:26] So I think frequency of meals does help. I talk a lot about, that concept of blood sugar management. I do talk a lot about really limiting drinking once we get into perimenopause and menopause. I think that's very important. I think that the sleep disturbances that occur, and I've seen this in myself. Even just going into menopause myself, the sleep disturbances have such a profound impact on our food intake, and we don't always recognize the correlation there, right. But we know from studies that if you're not getting good quality sleep, you were mentioning REM sleep that's a lot of studies there. You tend to eat more. It's the same as if you're doing an all-nighter in college. The next morning you're not looking for a kale salad, you're looking for a pizza, and you could eat half of it. [Cynthia chuckles]
[00:27:15] So there's a reason that occurs and that a lot of that has to do with our digestive hormones, the dysregulation of them when we don't get enough sleep. But we also know that that could also lead to increased cravings for sugar. I think it's such a frustrating time for women because we're going through so many changes. This is the bulk of my patient population as peri and postmenopausal women. But I think the quantity of food becomes the most frustrating piece. I'm eating nothing and yet I'm not losing weight. And so we have to look at, “Okay, if you're not eating anything, maybe that's the problem.” How do we take that perspective and change it so that now we're eating, but we're really focusing on the nutrient density.
[00:28:00] We're really focusing on foods that help your hormones. That's a better approach than, “You know what? I'm just going to throw in the towel. I'm not going to eat anything and in the meantime, I'm going to lose all my muscle, which we're at risk of losing anyway once we get into menopause.” So, we really have to work towards that. So, we're of missing the forest through the trees because we're just saying, “I'm just going to stop eating and cross my fingers that that works and it doesn't.”
Cynthia Thurlow: [00:28:24] How much of this is a byproduct of our toxic diet culture? Because I think that the one thing that I hear from women, and I always say, if they're saying this to me, I can just imagine what their internal dialogue is. As they are navigating this time and I have been there in perimenopause, weight loss resistant, frustrated. I was like, “Everything I've told my patients is not working for me. So, I think I need to rethink this paradigm.” But how many of us don't eat enough food? We don't nourish our bodies. We over fast. Like I'm known for intermittent fasting. But I tell people like, “The message should never be don't eat at all.” And I think for a lot of women, they think I need to exercise more, eat less food, just work harder. And some ways I think our bodies are, the word “pause” in perimenopause and menopause, I think is really important.
[00:29:08] It is forcing us to look at everything that we are doing through a different lens. And that maybe you've eaten too low carb for too long. You're earning enough protein, you're eating the wrong types of fats, you're not eating enough food chronically, habitually, and therefore your body thinks you're starving. So, it's going to hold on to everything. And to your point about sarcopenia, this muscle loss with aging. As that's happening, we're losing vital insulin-sensitive tissue or organs. And so that also, it's kind of like adding gasoline to a fire. So I'm curious what your thoughts are around kind of the prevailing diet culture that I feel like as a byproduct of a kid that grew up in the 70s and the 80s. It was Weight Watchers, it was Jenny Craig, it was these highly processed meals, teeny tiny portions, and that you used to just white knuckle your life to get through eating these teeny tiny portions to stay a teeny tiny person.
Kristin Kirkpatrick: [00:30:02] Right. The effect is that it makes us metabolically fatter. So, it's what happens from that metabolic perspective. I absolutely think even though we're seeing a shift in diet culture where we see really an increased awareness of this. It still persists day-to-day basis. I see this in my own patient population as well, and especially women comparing themselves to other women. So I see that as well, that really is part of it. I tell my patients that we have to recognize that we are unique genetically, culturally. And what diet culture takes away is our ability to really enhance our personal, our religious and our cultural preferences when it comes to food. All of that gets thrown away because now my preference has got to be, “I need to stay thin. And it's so hard so I need to take these drastic moves.”
[00:30:56] Yes, the body's holding on to everything, but in addition to that, again, you're looking at an environment in which you are hard programmed to just eat so much less. And I'm the same. I grew up in the 70s and 80s, and I remember the commercial of the Lays potato chip devil. And he's holding the potato chip, saying, “You can't eat just one.” And it's crazy to think about that commercial because they'd never have that commercial today because it's absolutely accurate. There's a reason why, when we get into this state, that it's really hard to stop eating the potato chips while we're sitting on the couch watching a TV show. And it's very easy to stop eating a whole bowl of broccoli.
[00:31:42] Now, it's not apples to oranges comparison, but there's something to be said for that as well, where we have been hardwired to understand that we need to adhere to portion control, but we forget that portion control doesn't work. It simply doesn't work. So again slowing down our rate of eating, having things that we enjoy, but figuring out how appropriate like, “When am I going to have those foods?” So I think diet culture is still there, and it's still hard for us to get those voices out of our head. But I think what you said is, like, “How are we going to nourish our body?” And that's the way we need to look at it, “Am I nourishing my body if I'm not delivering any nutrients through food and I'm taking 20 supplements a day, is that nourishment?” And the studies would indicate that it's not.
Cynthia Thurlow: [00:32:35] Yeah, it's so interesting because I think for each one of us, it's having these honest conversations with ourselves. I grew up with a mom that cooked everything. I mean, back in the 70s and 80s, my parents just didn't have the money to go out to dinner. I feel like my kids think it's commonplace [crosstalk] that they go to Cava or they go to Chipotle or whatever, that's normal. Explaining them that my mom made everything, even our bread. Like, she was crunchy before I even understood what that concept was. [Kristin laughs] And I had, which is why I don't drink milk to this day. I had milk with every meal. I had vegetables with every meal. She was a bit ahead of her time, and I'm grateful for that.
[00:33:13] Having said that, I think that we have been conditioned to believe as a society that cooking is a lost art, that it's not important that we can depend on the processed food industry to fill in the gaps. And I think that by divesting responsibility to the processed food industry, it has got us in this situation where we've been conditioned to believe that cooking is too hard. I'm the first person to say, “We have to kind of re-instill those habits.” Both my kids know how to cook. I always say, like, “I'm grateful for that.” That was maybe one of the blessings of the pandemic was that, we had four people living in a house 24/7, eating at different times because of school schedules, work schedules, etc. They had to learn how to cook because we did some food prep, but teenage boys eat everything and anything. What are your thoughts surrounding the role of exercise? Is exercise important? Is that something that you're talking to your patients about, especially those that have metabolic health issues.
Kristin Kirkpatrick: [00:34:16] I think I'm biased because I'm a dietitian, but I also think that we have plenty of data here. Diet will always trump exercise, right? There's that phrase, “You can't outrun a bad diet.” Something like that, right? But I do think when we think about the aging process and we think about this huge incidence that we are looking at in 2025 at increased risk of dementia, Alzheimer's, heart disease, all the cancers that we do know that exercise plays a very large role in the prevention of some of these risk factors. So, both resistance training and aerobic training are very important. But if I had a patient that said, “Hey, I only have 15 minutes, what should I do?” And it's a post-menopausal woman, I would put them straight towards resistance training. But if they said, “I only have 15 minutes, but I'm just going to exercise and not worry so much about my diet. That is a recipe for disaster.”
[00:35:19] I think diet got to be the most important component. Then we have a second conversation of, “How does my diet fuel the exercise regimen that I would like to have?” Exercise has been shown to be very beneficial for heart health, for brain health, for mental health, has not been shown to beneficial for weight loss, all right. So it's beneficial, I think, when we look at the studies for weight loss maintenance. But the process of weight loss is absolutely not accelerated by exercise, it is diet. And the other factors that go along with it doesn't mean we shouldn't exercise.
Cynthia Thurlow: [00:35:52] Yeah. No, I think that's such an important distinction. And typically, what I will say is, when someone says, I only have 10, 15, 20 minutes, take a walk after your meals.
Kristin Kirkpatrick: [00:36:01] Absolutely.
Cynthia Thurlow: [00:36:02] But nothing else we know that our muscles have these GLUT4 transporters. They're this great glucose disposal unit. Even if you have a glucometer or continuous glucose monitor, you can trend if-- you really just have that amount of time try to walk. Try to walk after your meal. We know that can be hugely impactful. What are your thoughts around carbohydrate restrictions? So, if they’ve known poor metabolic health, they're insulin resistant, maybe they're not yet diagnosed with NAFLD or this fatty liver, they're on that precipice, talk to us about carbohydrates because I think that carbs have been bastardized. I think that it's not to suggest all carbs are bad. There's certain types of carbs, depending on your metabolic health, that I think can beneficial. How does that enter into the conversation with your patients?
Kristin Kirkpatrick: [00:36:50] My patients think about carb restriction, that they go straight to keto, like, “Oh, God, I can't do keto. Oh, that sounds so awful.” But when we look at the studies on the benefits to blood sugar management, moderate carbohydrate diets have shown to be really effective. And moderate carbohydrate diets now that we have different definitions, we don't have an official definition yet, but if you look at all the studies, you pull all the data, it's about 45% of your calories coming from carbohydrates. So, a moderate carb diet is much higher than people think. Even a low-carb diet is 25% of your calories coming from carbohydrates. So, I think there is so much benefit to looking at the right carbs, obviously, versus I don't like to use the word the wrong carbs, but let's say the carbs that are so much easier to digest, right?
[00:37:41] So when we think about carbohydrates that come from a sweet potato, from quinoa, or from even nuts and seeds that might be higher in carb than other nuts and seeds, those have fibers. So I always say to my patients, anytime you have a carbohydrate, make sure there's a lot of competition for digestion. So, what does that mean? If I just have a big bag of licorice, there's no competition for digestion. My body is saying, like, “Oh, I love this. My endorphins are flying off the handle, and everything's great. Life is wonderful until my blood sugar drops, and then it's not.” There's no competition there.
[00:38:18] But if we go back to that example of an apple, now the body senses the simple sugar from the apple, which is satisfying. It's going to taste good. But then we also have fiber, and the body doesn't know how to process fiber. So it's like, “Okay, now I got this fiber.” So that slows everything down. That's kind of my main goal, is I tell my patients, “When you're going to have a carbohydrate, make sure that there's competition for digestion, make sure that there's fiber attached. And even better, add more competition. Add peanut butter or almond butter to that apple, add something else, like a healthy fat to that. So, make it as hard for the body to break down as possible, and the impact to insulin and blood sugar will be reduced.
Cynthia Thurlow: [00:39:00] I love that competition for digestion. That is a very important reframe. And I think for so many people listening, I was hospitalized five years ago for a ruptured appendix. I'll briefly explain this. It took me about 18 months after six weeks of antibiotics, antifungals, and ultimately getting my appendix removed, couldn't tolerate any fiber. The reason why I'm sharing this is that, if you're intolerant to fiber, sometimes it is quantity and sometimes it is a reflection of what's going on in the gut microbiome, because we should be at a point where we can tolerate some fiber. Now five years later, not an issue, but there were definitely a year or two where I wasn't able tolerate fiber. Do you find that for some women, they will share with you that they get bloated, they get gassy, it makes them constipated. I feel like bloat and constipation seem to be like, go together, like peanut butter and jelly. What are some of the things that you help them with if their concerns were expressed around being bloated or constipated vis-a-vis increasing their fiber intake? And we're not talking about, Metamucil and psyllium, we're just talking about whole food sources of fiber.
Kristin Kirkpatrick: [00:40:11] Well, first of all, I always encourage them to look at potential food sensitivities. So that's one place where we would start looking at, “Is there something going on there?” But in terms of increasing the ability to get stool out of the body, and I had a patient the other day that said, “Oh, gosh. Yeah, I've been really constipated for the past six months.” And I'm like, “Well, what's normal?” Well, normal is typically, “I'd go every day and I'm going every fourth or fifth day, but it doesn't bug me.” And it's kind of like, “Well, it should because we're not moving things through the body.” And so we have to go back to, “Why is that happening?”
[00:40:50] So really looking at a combination of both soluble and insoluble fiber, I think when we look at the Metamucil’s of the world, we look at all these supplements, it's insoluble fiber that's the key factor because it moves bulk through. But really, we know from the studies both types of fiber are really important. So I think looking at, “All right, what has high quality fiber? Berries, nuts, seeds, complex carbohydrates.” I tell my patients, if you're really struggling with constipation, then let's switch from having whole grains in the diet to intact whole grains.” So let's now have grains that have not been altered in any way, shape, or form. So instead of having whole wheat pasta, we're going to have wheat berries, and we're going to add that to let's say, quinoa or brown rice.
[00:41:36] So now we have something that hasn't been altered in any way, shape, or form. Steel-cut oatmeal is a great example of that. Oatmeal, in general is very good for us, but steel-cut oatmeal is intact versus old fashioned oatmeal that has been flattened. So again, it sounds so like, “Wow, you're really being nitty gritty on this one.” But intact grains tend to have a little bit more roughage, and most people respond to that word of roughage and then just getting more plants in. So, I think what we do to try and kind of combat this without taking a supplement is we'll have certain foods, we'll have bars, we'll have things like that have fiber added into it. Well, that's no different really from taking a supplement in some ways.
[00:42:19] So again, like, “How can we get whole foods approach more plants?” Because that's the only place we'll get fiber and a slow progression of it. So that's the other thing, when people come to my office and they're like, “Steady stream of fast food and now they're gung-ho,” and it's like, “Hey, I'm going to get 25 g of fiber this week.” I'm like, “Whoa, your body's not ready for that.”
Cynthia Thurlow: [00:42:40] [laughs] No.
Kristin Kirkpatrick: [00:42:41] Not ready for that. So let's focus on getting five to seven every day, and then let's see how your body reacts to that. And then we'll bump it up, then we'll bump it up.
Cynthia Thurlow: [00:42:52] Well, I love that. The caution around going overboard with fiber. If you're currently consuming 10 g or less, which is what I believe the standard American diet affords us, and you're trying to work up to 40 or 50, you need to do it slowly, otherwise you're going to have the bloating, the constipation, digestive distress, which I can't think of anyone who wants to experience that, you have to kind of go low and slow.
Kristin Kirkpatrick: [00:43:14] Yeah.
Cynthia Thurlow: [00:43:15] What's interesting to me, the other piece of the toxic diet culture that I find interesting is we will try to out supplement our crappy diets with more supplements. And supplements have a place, let me be clear, strategic targeted supplementation in addition to eating a nutrient-dense diet. But if you're thinking by taking your-- I don't know, your special fiber product in a capsule, somehow that's going to outdo all the processed food you're eating, you'd better off investing that money into eating less processed foods. Easier said than done of course. So that’s my segue into talking about supplements. But for your patients in particular, I’m thinking green tea, coffee, these ancillary aspects to nutrition that can beneficial. Are there any particular supplements that you are talking to your patients about, again, relative to metabolic health that you think are beneficial in conjunction with a nutrient-dense diet?
Kristin Kirkpatrick: [00:44:16] Yeah. It's interesting, most of my patients have some aspect of metabolic health or metabolic dysfunction going on. So when I see that, my first question to them is, “Okay, I know why you're here to see a dietitian. But what I'd like to find out from you is, what is your why?” And I describe that, right? And I tell people, even if your why is weight loss, I don't want that to be your why in this conversation. I want something that's more meaningful. So, let's really dive into that. And that's when people start having more conversation, “Okay. Well, my mother has Alzheimer's. I don't want to turn into her. That's my, why?” So once I hear the why, I know, “Okay, let's now look at your diet and let's look at what we're trying to increase. But it's really a challenge for you.” So, for example, I had a patient the other day whose why was Alzheimer's prevention? She happened to be carrying a gene that made her more at risk for Alzheimer's.
[00:45:11] So when I looked at that, I looked at her diet and I was like, “Gosh, what's the ability of your diet to increase fatty fish? Can we get more omega-3s? And she's like, “Oh, I hate fish.” So that's a situation where I know, “Okay, we have to have some sort of supplemental fish oil based on the studies.” But that might not be another patient that I would see right after her that doesn't have that, why? and that eats two to three servings of salmon every week. So, it just is really dependent on what's the diet look like. I think that, and I had a patient literally yesterday, she was self-proclaimed, it's not my words, it's her words. She came in saying, “I have a horrible diet.” She did, it was very low in nutrient density, high-processed food, and had been for decades. And she came in and she said, “I started taking this probiotic on Monday and I just have awful stomach pain, I have bloating, I feel horrible. And I was hoping you could give me a different brand.” [Cynthia laughs]
[00:46:06] I said, “Well, it's not the brand. It's that your body was not used to that microorganism because it hadn't seen it before.” Your microorganisms are microorganisms that are feeding disease and feeding inflammation. A probiotic is going to add in something that helps to offset that. Your body wasn't ready for that huge amount. So, we need to take other steps before we start thinking about that. Or we'll take a lower dose of probiotic and then four days later we'll take another lower dose. Taking it every day, I'm not surprised you're sitting in front of me saying, “Oh my gosh, probiotics stink.” We have to look at where we came from and then what's the why? And that really is dependent on it. Across the board, vitamin D is going to be something that I would recommend. Our body doesn't really metabolize it well, maybe a B complex, just depending on how many plant-based sources, maybe a magnesium, based on things that are going on. But the supplement conversation is really the key to personalized nutrition.
[00:47:11] There's not a one size fits all approach, just like there's not a one size fits all diet approach. So your supplements are going to be based on your unique needs, your nutrigenomics analysis. Well, look at that as well. And what's your why? What do you want to avoid across all other means that you've seen occur in your family that's going to maybe determine that as well.
Cynthia Thurlow: [00:47:31] I think that's really important for everyone listening, understanding that we're our own bio-individuals. We probably all have things that we're concerned about, susceptibilities. My husband comes from a family where people die of cancer and that his dad passed away from cancer. And so that is at the forefront of his mind when he’s meeting with new clinicians, even though he’s very healthy. My end of the family, they usually have some degree of vascular disease. And so for me it’s a different kind of thought process. But obviously good clinicians like yourself, you invite those kinds of conversations. I’d love to round out the conversation. You mentioned nutrigenomics. Let’s talk about what this is. I think this is so interesting. We’ve actually run reports on my kids. Explain to listeners the value of looking at this particular type of testing, “Do you go through Genova to do that?”
Kristin Kirkpatrick: [00:48:19] No. We have been offering nutrigenomics at Cleveland Clinic for about eight years and we use two testing mechanisms. We use nutrigenomics out of University of Toronto and then we use 3X4. So, nutrigenomics is used integrative medicine, 3X4 is used in functional medicine. They have different genotyping that they're looking at. But to sum it up very easily, nutrigenomics simply looks at your genetic makeup and how it is influenced. So that gets into epigenetics to your lifestyle. All right, so we know that you can't change your genes. That's obvious, but we do know that we can change how a gene is expressed in some instances. I would say the bulk of my patients are nutrigenomic patients and those are typically people that say, “Okay, I've really been doing everything right, now I want to know from a genetic standpoint what works best for me and what I need to watch for.”
[00:49:20] So if we go back to even something like the keto diet. We know that there are certain genotypes that won't really do great on a keto diet. So that's the thing, it's like looking at our genetics. I mean that's a great example of where, “All right, maybe we do need to look at a B12 because you've got this genotyping going on that makes it less efficient for B12 to get transferred from cell to cell. Let's test you first, let's see what your B12 level is and then we might have to go with supplements because it's going to take more than food. So it's really beneficial to look at nutrigenomics testing. I'm clearly biased, but I think it is the first steps towards looking at what are some of the personalized ways that I can change my dietary pattern based on my genetics.
Cynthia Thurlow: [00:50:06] It's so interesting because I was just reading a paper talking about ketogenic diets and how they work well, for some, but not all. And it has a direct reflection of what's going on in the gut microbiome. So some patients will say to me, “I did a ketogenic diet. I feel great. I feel amazing.” They go from a standard American diet to a ketogenic diet, or it is the, I went from a standard American diet or an ultra-processed diet predominantly to keto, and I gained 10 pounds seemingly overnight. [chuckles] And I'm like, “Well, it could have something to do with your genetics.” It could also have something to do with the fact you can't go from eating an ultra-processed diet, eating a stick of butter and a pound of bacon every day, and necessarily think that that per se is going to work out well.
[00:50:47] Well, I so love this conversation. Please let listeners know how to connect with you, how to purchase your coauthored book, which I think is an incredible resource on liver health. Really looking at metabolic health vis-a-vis the liver.
Kristin Kirkpatrick: [00:51:00] Yeah. Thank you. They can go purchase my books through my website, which is just kristinkirkpatrick.com. Kristin spelled with an I or social media, if they can do it that way. And that's where I share recipes, tips, all of that. And that's @fuelwellwithkrissy.
Cynthia Thurlow: [00:51:15] So, nice to meet you.
Kristin Kirkpatrick: [00:51:17] Great to meet you. Thank you so much.
Cynthia Thurlow: [00:51:19] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
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